
Book ^Lx.^ 

Copyright N? 



COPYRIGHT DEPOSIT. 



1 



%£»« 






8$b§ 



&S§HSf 









INFANT-FEEDING 



ITS PRINCIPLES AND PRACTICE 



J* BY 

Ff>X. WACHENHEIM, M.D. 

ATTENDING PEDIATRIST, SYDENHAM HOSPITAL AND MOUNT SINAI DISPENSARY 
NEW YORK CITY 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1915 



T(3 £\6 



Entered according to the Act of Congress, in the year 1915, by 

LEA & FEBIGER, 
in the Office of the Librarian of Congress. All rights reserved. 



JAN -6 1915 
©CI.A393193 



- 



i 



DEDICATED 

TO 

MY FIRST TEACHER IN PEDIATRICS 

DR. ABRAHAM JACOBI 



PREFACE. 



This manual is designed to supply the practitioner 
with a reference hand-book, of moderate size, in 
which he may find an exposition of the present theory 
and practice of infant feeding. The material here 
presented can only be secured by reading a vast 
journalistic literature, which is extremely conflicting 
in its statements and of little practical use, without 
extensive sifting. 

In giving some five hundred literary references I 
have endeavored to select the articles that are most 
valuable and accessible, sometimes regardless of priority. 
These references do not, of course, include a tithe of 
the immense literature on this subject, but the reader 
will find most of the leading articles of the last decade 
duly noted. 

F. L. W. 

New York, 1915. 



CONTENTS. 



CHAPTER I. 
Infantile Digestion and Metabolism. 
Digestion; protein metabolism; fat metabolism; the 
infant stools; carbohydrate metabolism; salt metabo- 
lism; growth and weight; caloric requirement ... 17 

CHAPTER II. 

Breast-feeding. 
Colostrum ; composition'of humanmilk; milk secretion; capa- 
city for nursing; contra-indications to nursing; physical 
and chemical tests; rules for breast-feeding; difficulties 
in breast-feeding; wet-nursing; preserved breast-milk . 48 

CHAPTER III. 
Cow's Milk. 
Composition; analysis of cow's milk; the proteins; the 
fats; the carbohydrates; the salts; the ferments; the 
bactericidal property of milk; milk bacteria; milk 
infection; milk regulations; sterilization; pasteuriza- 
tion; condensed milk; desiccated milk; frozen milk; 
preserved milk; milk stations; whole-milk feeding; 
milk idiosyncrasy; milk of other animals .... 76 

CHAPTER IV. 
Milk Modification. 
Simple dilution; removal of the casein, whey; removal of the 
fats, skim milk; removal of casein and fat; butter- 
milk; removal of whey, albumin milk, albumin-cream- 
milk; addition of fat, top milk, Biedert's mixture, 
Meigs' mixture, Rotch's method (percentage feeding), 
Gartner's fat milk, Szekely milk, Niemann's modifica- 
tion; addition of protein and fat, casein-fat-milk, whey- 
modified milk Ill 



Vlll CONTENTS 

CHAPTER V. 

Milk Modification (continued). 

Addition of carbohydrates, malt, dextrin, starch; Jacobi's 
method, the author's modification, Pfaundler's varia- 
tion; Keller's method; caloric feeding; the addition of 
alkalies; the addition of ferments, proteolytic, glyco- 
lytic; lactic acid fermentation; alcoholic fermentation; 
homogenized milk; baby foods 144 

CHAPTER VI. 
Other Infant Foods. 

Beef-juice; beef-extract; meat-broth; eggs; leguminous 
vegetables; carrots: hemp-soup; banana-meal; addition 
of water to diet 174 

CHAPTER VII. 

Artificial Feeding. 

The present situation; general recommendations; consti- 
pation; colic; vomiting; diarrhea; soap stools; feeding 
in the second half-year; mixed feeding; the feeding 
of premature infants 184 

CHAPTER VIII. 

Disorders of Digestion. 

Physical disorders: pyloric stenosis; pylorospasm; mega- 
colon; singultus; rumination; digestive neuroses . . 206 

CHAPTER IX. 
Disorders of Digestion (continued). 

Alimentary disorders: protein indigestion; fat indigestion; 
carbohydrate indigestion; salt disturbances; Finkel- 
stein's theory: disturbed equilibrium, dyspepsia, 
atrophy, intoxication 220 



CONTENTS ix 

CHAPTER X. 

Disorders of Digestion (concluded). 

Infectious disorders: etiology, pathology, symptoms, 

prognosis, prophylaxis, treatment 243 

CHAPTER XI. 

Disorders of Metabolism. 

The exudative diathesis; anemia; acidosis; the metabolic 

dermatoses: eczema, urticaria 267 

CHAPTER XII. 

Rickets and Scurvy. 

Rickets: etiology, symptoms, diagnosis, prognosis, treat- 
ment; spasmophilia. Scurvy: etiology, sympto- 284 
matology and diagnosis, treatment 

CHAPTER XIII. 

The Feeding of Older Infants. 

Weaning; feeding during the third half-year; feeding 

during the fourth half-year; feeding troubles . . . 308 

Bibliography 321 

Index . .... 333 



INFANT-FEEDING. 



CHAPTER I. 
INFANTILE DIGESTION AND METABOLISM. 

Saliva is secreted at birth; diastase (amylase) is 
present in it and very active at birth; maltase and 
potassium sulfocyanid appear later (Ibrahim 1 ). The 
quantity of saliva is from 10 to 20 per cent, of the 
volume of the ingested food (Allaria 1 ). The act of 
sucking starts a free flow of saliva through the secre- 
tory salivary reflex (Ibrahim 1 ). 

The mixture of saliva with the ingested milk facili- 
tates the penetration of the rennin-casein curds that 
are formed in the stomach by the hydrochloric acid 
of the gastric juice (Allaria 2 ). The diastase works 
best in a feebly acid medium, and therefore continues 
to act during the earlier period of gastric digestion 
so long, as there is little or no free hydrochloric acid 
in the stomach contents (Chittenden and Griswold). 

The act of sucking also starts the flow of gastric 
juice (Nothmann 1 ). Hydrochloric acid, pepsin, rennin, 
and lipase are present at birth even before any food 
is given (Hess 1 ). Free hydrochloric acid does not 
appear in the stomach contents until an hour or more 
2 



18 INFANTILE DIGESTION AND METABOLISM 

after a meal (Leo) ; its secretion is favored by alkalies, 
large doses of which interfere with the gastric digestive 
function, but is retarded by an excess of sodium 
chlorid, sugar, or fat in the ingesta, as well as by 
prolonged starvation. The total acidity is highest 
two or three hours after feeding, according as the 
infant is breast-fed or bottle-fed (Heiman 1 ). The 
rennin coagulates the milk-casein, but it is still doubtful 
how far the pepsin peptonizes the proteins. Davidsohn 
thinks that rennin and pepsin are identical. 

Lipase was first found in the stomach by Volhard; 
in the infant stomach by Sedgwick; 1 it splits only a 
small proportion of the ingested fats in the stomach, 
but continues active in the upper portion of the small 
intestine (Sedgwick and Schlutz). 

Of organic acids, only lactic acid is occasionally 
found in the stomach of breast-fed infants; in bottle- 
fed infants the volatile fatty acids, especially butyric 
acid, are not infrequently present (Heubner 1 ). 

High acidity favors closure of the pyloric orifice, 
but the stomach begins to empty itself about the 
time that free acid appears, that is, about an hour 
after the ingestion of breast-milk, and about two 
hours after artificial feeding (Czerny and Keller). 
The stomach is entirely emptied about an hour and 
a half later, but high fat percentages and excessive 
dilutions of cow's milk lengthen this period, whereas 
moderate dilutions, up to half and half, shorten it 
(Tobler and Bogen). 

The stomach capacity of the normal infant has 
often been much underrated. The customarv short 



. 



DIGESTION 



19 



feeding-interval, which rarely permits the stomach 
to empty itself thoroughly, gives figures that are far 
too small. The following table, compiled from the 
data of a number of investigators, gives in ounces 
the total daily amount of food and the average quan- 
tity taken at each feeding. The figures refer to breast- 
fed infants, nursed five times a day, at four-hour 
intervals, and were obtained by careful weighing 
immediately before and after feeding. 



Age . . . 


. One 


Two 


Three 


Four 


Five 


Six 


One 




day. 


days. 


days. 


days. 


days. 


days. 


week. 




oz. 


oz. 


oz. 


oz. 


oz. 


oz. 


oz. 


Per day 


2 


4 


6 


8 


10 


11 


12 


Per meal 


0.4 


0.8 


1.2 


1.6 


2 


2.2 


2.4 


Age . . . 


. Two 


Three 


Four 


Five 


Six 


Seven 


Two 




weeks. 


weeks. 


weeks. 


weeks. 


weeks. 


weeks. 


mos. 




oz. 


oz. 


oz. 


oz. 


oz. 


oz. 


oz. 


Per day 


14 


17 


20 


22 


24 


26 


28 


Per meal 


2.8 


3.4 


4 


4.4 


4.8 


5.2 


5.6 


Age . . . 


. Three 


Four 


Five 


Six 


Seven 


Eight 






mos. 


mos. 


mos. 


mos. 


mos. 


mos. 






oz. 


oz. 


oz. 


oz. 


oz. 


oz. 




Per day 


. 30 


32 


33 


34 


35 


36 




Per meal 


6.0 


6.4 


6.6 


6.8 


7.0 


7.2 





The quantities given by the percentage method 
according to Ladd's 1 table (V, p. 129) are as follows: 

Age One Two Three Four Six 

week. weeks. weeks. weeks. weeks, 

oz. oz. oz. oz. oz. 

Per day 10 15 18 20 24 

Per meal .... 1 1.5 2 2.5 3 

Age Two Three Four Five Six Eight 

mos. mos. mos. mos. mos. mos. 

oz. oz. oz. oz. oz. oz. 

Per day .... 24 . 5 28 27 33 36 42 

Per meal ... 3.5 4 4.5 5.5 6 7 

Ladd's figures for the stomach capacity are certainly 
too low for the early months of infancy, and his totals 
per day, from the eighth month onward, at present 
are considered excessive. Forty ounces per day should 



20 INFANTILE DIGESTION AND METABOLISM 

be the maximum amount of fluid given, and many 
foreign pediatrists set the limit at thirty-two ounces, 
or one quart. 

The secretion of bile begins within twelve hours 
after birth, and rapidly becomes profuse, being fully 
established within a week or ten days. Failure of the 
organism to get rid of the secreted bile with equal 
rapidity is the probable cause of icterus neonatorum 
(Hess 2 ). The long accepted theory of Quincke, which 
makes the presence and intensity of icterus neonatorum 
depend on the relative patency of the ductus venosus, 
has never been sufficiently substantiated by experiment, 
and is probably at the most a partial explanation. 

All the pancreatic ferments are present, though 
scanty, in the newborn; their quantitative develop- 
ment is as follows: lipase increases rapidly in amount 
(Hess 3 ), trypsin less rapidly, but more so than the 
diastatic ferment (Friedlander) . The secretion of 
pancreatic juice is not suspended even in severe ill- 
ness, but the lipase undergoes a marked decrease 
(Hess 3 ). The secretion does not cease if the pro- 
duction of gastric juice is scanty, but, on the other 
hand, it is not promoted by the entrance of free hydro- 
chloric acid into the duodenum (Hess 1 ). It should 
be remembered that trypsin and the pancreatic lipase 
are both secreted as zymogens, the former being 
activated by the enterokinase secreted by the small 
intestine, the latter by the bile (UfTenheimer) . 

The precision as to the facts just stated is due to 
the employment of the stomach tube and duodenal 
catheter. Below the duodenum our knowledge is 



DIGESTION 21 

necessarily less exact, not only with regard to the 
stages of digestion but also with respect to the sites 
of ferment activity. Besides the complementary 
action of the enterokinase, just mentioned, the ferment 
erepsin converts the previously formed protein deriva- 
tives into crystalloids of the amino-acid group, which 
appear to be absorbed directly (Folin), while maltase, 
invertase, and lactase exert their several specific actions 
on the carbohydrates. Diastatic action is feeble or 
absent in the intestinal secretion. Our information 
as to the minor details of digestion in the jejunum 
and ileum is still somewhat defective, because of the 
technical difficulties involved in this field of research. 

We must note that the intestine is relatively long 
in infants, in proportion to the body length, and its 
musculature comparatively feeble; digestion is there- 
fore relatively slow and thorough, but, on the other 
hand, more subject to derangement by such substances 
as are either directly toxic, or influence the peristaltic 
function. The excessive length and tortuousness of 
the sigmoid flexure tend to favor constipation in infants 
whose muscular system is underdeveloped. 

Infants vomit with comparatively little effort; 
the food seems almost to overflow from an overloaded 
stomach. This phenomenon is certainly not due to 
remarkable vigor of the gastric muscularis, but is 
associated with the relatively feeble closure of the 
cardiac orifice in early life. 

The secretion of hydrochloric acid keeps the 
stomach contents relatively germ-free, and the upper 
intestine is likewise nearly free from bacteria, because 



22 INFANTILE DIGESTION AND METABOLISM 

of the antibacterial nature of the intestinal secretion. 
This safeguard largely fails in the presence of diges- 
tive disorders and during starvation (Moro 1 ) ; on the 
other hand, abnormal bacteria are rapidly eliminated 
by the healthy intestine, though the process may be 
accompanied with diarrhea (Jehle and Pincherle). 
Bacteria swarm in the large intestine, the species 
varying greatly according to the nature of the food 
and the condition of the digestive functions. 

The passage of the ingesta through the gastro- 
intestinal tract is normally accomplished in eighteen 
to twenty-two hours, according to tests with carmine, 
made by Triboulet, which require confirmation by 
other investigators. Bahrdt and Bamberg have shown 
that peristalsis is increased by a daily dose of 0.2 to 
0.5 gram of acetic acid, less so by a similar dose of 
the other volatile fatty acids, and not at all by lactic 
acid. The acids, that are normally found in the diges- 
tive tract, do not therefore affect peristalsis perceptibly, 
under ordinarv conditions. 



PROTEIN METABOLISM. 

We are in possession of quite a number of studies 
on the protein metabolism of infants. The earliest, 
made by Rubner and Heubner, are still among the 
best, and are wonderfully thorough; those of Keller 1 are 
extremely valuable. Among more recent investiga- 
tions, those of Hoobler 1 are particularly useful, partly 
because they deal with rather high protein and fat 
feeding. 



PROTEIN METABOLISM 23 

Hoobler's 1 data for the ultimate disposition of the 
proteins, measured as nitrogen, are as follows: 

Percentage passed in feces . . . 3.9 

Percentage absorbed 96.1 f as urea . . .45.4 

■o . , . . . r , y - J as ammonia . . 9.5 

Percentage passed in tinne . . . 63.7 < . n ., Q n 

as amino-acids . 8.0 

Percentage passed in urine and feces 67.6 as creatinin 0.8 

Percentage retained 32.4 

I have corrected Hoobler's figures slightly, to elimi- 
nate some obvious mathematical errors. Hoobler does 
not allow for the nitrogen derived from the metabolism 
of the intestine itself, whereby he would show the 
nitrogen loss through the feces to be still smaller. 

If we turn to the amounts of protein and nitrogen, 
ingested by the normal infant we obtain the following 
figures : 

Early Six Ten 

infancy, months, months. 

Gm. Gm. Gm. 

Protein 10 25 40 

Nitrogen 1.6 4 6.4 

Nitrogen per kilo of weight . . 0.3 0.5 0.7 

Early infancy is well represented by Keller's 1 data 
for an eleven-pound infant (5 kilos). Rubner and 
Heubner's subject weighed seventeen pounds (8 kilos) ; 
Hoobler's a trifle more. The first two seem to have 
been slightly underfed, if we are to judge by the daily 
weighings; the third was apparently somewhat over- 
fed, but without showing any signs of digestive dis- 
turbance. 

The essential accuracy of these researches seems 
to be shown by their substantial agreement; the 
three infants retained respectively 36, 26, and 32 
per cent, of the ingested nitrogen. The daily observa- 



24 INFANTILE DIGESTION AND METABOLISM 

tions, however, show very considerable fluctuations, 
especially with respect to the urinary ingredients, 
so that our present knowledge on this subject can 
be regarded only as approximate. The unavoidably 
short periods of observation, averaging seven days, 
have undoubtedly affected the value of the results 
materially; the chief obstacles have been, and probably 
will always be, the technical difficulties and the vast 
amount of labor involved in these and similar investi- 
gations. 

Some points, indeed, appear fairly well settled. 
(1) Very little available nitrogen is lost in the feces 
of the normal infant; we shall see, however, that this 
applies solely to animal proteins, and that the absorp- 
tion of vegetable proteins, for example, from cereals, 
is very much less complete. (2) We may, with Hoobler, 1 
assume with some confidence that about one-third 
of the ingested protein is assimilated, regardless of 
the quantity given. This figure, however, does not 
apply to colostrum feeding, as met with in the earliest 
period of breast-feeding. In this matter Birk 1 sustains 
the older reports of /Michel, which gave twice as 
high a ratio of protein assimilation in the newborn. 
Birk 1 shows that this difference is intimately connected 
with colostrum feeding, because it does not occur 
in artificially fed newborn babies, who assimilate 
only about one-third of the ingested protein. A good 
resume of the whole subject is given by Schwarz. 1 

Frank and Schittenhelm have shown that the 
different milk proteins are absorbed about equally 
well, and similar utilization is made of the other 



PROTEIN METABOLISM ' 25 

animal proteins. Chittenden and Mendel claim that 
the absorption of vegetable proteins is about the 
same, but admit that they arc thoroughly digested 
only when isolated; in their usual association with 
indigestible matter, such as cellulose, their absorption 
is imperfect. Milner and Atwater give a percentage of 
availability ranging from 72 to 88 per cent., the latter 
for fine wheat flour, whereas, as we have seen, from 96 
to 98 per cent, of the animal proteins are digested. 

There has been considerable discussion as to the 
presence of creatinin in the urine of healthy infants, 
but the finding of this substance, by Sedgwick, 2 in 
the liquor amnii, proves that it is a normal urinary 
constituent. High fat percentages in the milk do not 
affect protein absorption, but seem to increase the 
proportion of nitrogen excreted in the urine as 
ammonia (Hoobler 1 ). The excretion of nitrogen is 
increased by the administration of thyroid extract, 
but this is accomplished at the expense of the body 
proteins (Orgler 1 ). Some of the scanty excretion of 
nitrogen in the feces is not of alimentary origin, but 
is derived from the intestinal secretion and detritus 
(Orgler 2 ), so that the absorption of the proteins is 
even better than the figures would indicate. 

As shown in the preceding table the normal intake 
of protein per kilo of weight is approximately doubled 
during the first year, after which period it slowly 
declines. There is evidently a smaller requirement 
of nitrogenous matter in early infancy than later on, 
but the reason for this difference has not yet been 
given. We must, however, bear in mind that the 



26 INFANTILE DIGESTION AND METABOLISM 

proteins, while indispensable to the growth and, 
more particularly, the muscular development of the 
body, play a minor part in the daily metabolism. An 
increase in weight cannot be obtained by ever so liberal 
a protein diet; even if it were possible to supply the 
theoretical caloric requirement in the form of nitrogen 
compounds, the body weight would nevertheless decline. 
This point will be more fully elucidated later on. 

A few remarks on the purin bodies may not be 
amiss. It is well known that the kidneys, in the 
newborn, excrete a very large amount of uric acid, 
sufficient to form tube casts, and load the urine with 
an abundant red sediment. As this excess of uric acid 
is attended with a corresponding increase in the excre- 
tion of phosphates, we need not hesitate to refer it to 
the breaking up of nuclein, caused by an enormous 
postnatal destruction of leukocytes. As a matter of 
fact a marked polymorphonuclear leukocytosis appears 
at birth, which rapidly gives way to the normal infantile 
lymphocytosis. As the polymorphonuclear cells decline 
in number to the extent of about 20,000 to each cubic 
millimeter of blood, about 4,000,000,000 in all, the 
excretion of uric acid and phosphates rapidly rises 
to its maximum, speedily falling to the usual ratio, 
when the blood-count has reached its normal propor- 
tions, the entire process consuming about a week 
(Schloss and Crawford). 

Aside from the occasion just discussed, the excretion 
of uric acid is relatively very low in infancy, because 
the baby's normal diet is particularly free from purin 
bodies, milk being quite exceptional in this respect. 



FAT METABOLISM 27 



FAT METABOLISM, 



Of the ingested fat a little is split by the gastric 
lipase, more by the pancreatic lipase, still more is 
merely emulsified by the intestinal secretion. Neutral 
fat cannot be absorbed (Connstein); it must pass 
through the intestinal wall as either an emulsion or 
an alkaline soap, and is believed to do so chiefly as 
the former. Both fat derivatives are rapidly converted 
back into neutral fat, which is practically the only 
fatty compound found in the lymph stream, but the 
exact manner and place of this reversal is still obscure 
(Whitehead, Mendel 2 ). In all, from 90 to 98 per cent, 
of the ingested fat are absorbed under the normal 
conditions of breast-feeding (Czerny and Keller), 
and this takes place almost exclusively in the small 
intestine, for absorption by the stomach is practically 
nil, and in the colon it amounts to very little. 

Osborne and Mendel have shown that milk-fat con- 
tains certain ingredients essential to the growth of 
young animals that are absent in the ordinary fats; 
McCallum and Davis find the same properties in egg- 
fat, and Mendel 2 finds them in cod-liver oil. 

The Infant Stools. — The stools of the infant furnish 
the most available means of studying its fat metabolism ; 
one of the best brief descriptions of the various types 
of intestinal evacuations is furnished by Morse. 1 

Fat and its derivatives form about 50 per cent, of 
the dried feces in early infancy; as the infant grows 
older the ratio gradually falls to one-half and one- 
fourth of this amount. In later infancy, neutral 



28 INFANTILE DIGESTION AND METABOLISM 

fat and alkaline soaps each amount to about 10 per 
cent, of the total stool fat, the remainder consisting 
of varying proportions of free fatty acids and soaps 
of the alkaline earths (Usuki). We must not forget 
that a moderate amount of free fatty acid in the infant 
stool is normal (Escherich 1 ) . 

The normal breast-milk stool is semisolid, of a light 
yellow color, an acid but not fecal odor, and spreads out 
quite smoothly; signs of undigested fat should not be 
obvious, the visible evident presence of soft, yellowish- 
white fat masses, commonly but inaccurately designated 
as fat-curds, is always on the borderline of the patho- 
logical, though subjective symptoms of indigestion may 
be lacking. The stools of bottle-fed infants are more 
than twice as voluminous (Rubner and Heubner), 
chiefly because they contain a much larger proportion 
of fat and fat derivatives; the odor is different, with 
a tendency to rancidity; and the occurrence of visible 
fatty particles is both more frequent and of more 
serious import. In addition, under certain conditions 
to be specified later, we observe true cheesy curds, 
hard, white, and more or less bean-shaped, which 
must be carefully distinguished from the so-called 
fat-curds. 

Soap stools are found only in artificially-fed infants. 
They are pale or earthy yellow in color, of a firmer 
consistency than normal stools, and have been aptly 
compared to putty. They owe their appearance and 
greater solidity to the presence of large quantities of 
the insoluble soaps of calcium and magnesium. Soap 
stools are the characteristic feces of infants who suffer 



FAT METABOLISM 29 

from poor fat absorption, without signs of acute or 
subacute indigestion. 

All infant stools contain some free fat, but the so- 
called fat stools contain it in large amount. They are 
bright yellow, visibly oily, and leave a grease spot on 
linen and paper. They are invariably a sign of almost 
total failure even to emulsify, much less to digest, 
the food fats, and therefore a valuable sign of serious 
functional derangement; their bearings on infant 
dietetics will be more fully discussed later on. 

Mucus is not normally present in the stools in suffi- 
cient amount to be macroscopically demonstrable; 
neither is it found in soap stools, for the formation of 
mucus tends to check saponification (Hecht). It 
is, therefore, when present in any quantity a trust- 
worthy sign of serious digestive disturbance, and is 
practically found only in the presence or as a conse- 
quence of bacterial infection of the intestinal wall. 

Talbot 1 recommends the following tests for the 
microscopic determination of the different fat deri- 
vatives in the feces. Carbol-fuchsin does not stain 
neutral fat, stains the fatty acids bright red, and the 
soaps dull red. A 5 per cent, alcoholic solution of 
Sudan III does not stain soaps, stains neutral fat 
red, fatty acid droplets red, fatty acid crystals unevenly. 
These tests, being merely qualitative, are of course 
of limited value for exact diagnosis. Cowie and Hub- 
bard estimate the fats in the stools of infants by 
means of a modification of the Babcock method. 

Green stools have recently become the subject of 
thorough investigation. Wernstedt's discovery of a 



30 INFANTILE DIGESTION AND METABOLISM 

peroxid-splitting ferment in the feces has been utilized 
by Koeppe 1 in the study of this question. Koeppe 1 
finds that the green color is due to three factors: first, 
the presence of a peroxid; secondly, the peroxid- 
splitting ferment; thirdly, a coloring matter turning 
green with nascent oxygen, probaly bilirubin. He 
conceives that this reaction may take place under 
conditions of perfectly normal digestion, but this 
hypothesis needs substantiation. It is better to 
consider green stools as symptoms of a pathologic 
digestive or metabolic process, possibly of very diverse 
significance. No good explanation has yet been offered 
of the relative frequency of this phenomenon in infancy. 
During the first few days of life, instead of true 
feces, the infant passes the dark brownish-green sub- 
stance known as meconium, which is not derived from 
the digestive processes, but consists of the fetal debris 
of the digestive tract and its accessory glands. The 
addition of true fecal matter to the meconium sets 
in after two to five, usually three or four days, and 
the evacuation of typical milk stools is fully estab- 
lished in from five to twenty, on the average ten days. 
The precise determination of this last date is sometimes 
difficult, as the feces may still be somewhat greenish- 
brown on the surface, and yet show the normal yellow 
color, when spread out (Southworth 1 ) . 

CARBOHYDRATE METABOLISM. 

In considering the metabolism of the carbohydrates, 
we must distinguish between infants fed with the 



CARBOHYDRATE METABOLISM ol 

normal sugar of milk (lactose), and those fed with 
other carbohydrates, of which the digestion and assimi- 
lation are still perfectly possible within physiological 
limits. 

As milk-sugar (lactose) cannot be absorbed as such, 
and as the milk-sugar splitting ferment, lactase, is 
secreted only by the small intestine, the metabolism 
of this carbohydrate does not begin until the duo- 
denum has been passed. The ferment lactase is present 
from earliest infancy, for Nothmann 2 found it in a 
series of premature children; lactase splits lactose 
into galactose and glucose, both of which are absorbed, 
conveyed by the portal blood-stream to the liver, 
and there converted into and stored as glycogen. 

Cane-sugar (saccharose), like most of the other 
disaccharids, is not absorbed as such, but must first 
be split by the invertase of the intestinal secretion 
into the two glucoses, dextrose, and levulose, which 
are readily absorbable. Maltose (malt-sugar) occupies 
an exceptional position among the disaccharids, in being 
partly absorbable as such. This is probably due to 
the fact that it can be split not only by the maltase 
of the digestive juices, but also by the same ferment 
being present and active in the circulating blood 
(Chittenden and Mendel). 

To a certain extent, starch may also be assimilated 
by the normal infant. It must first be changed to 
dextrin by the diastase of the saliva, which we have 
shown to continue active during the earlier stages 
of gastric digestion, as well as by the same ferment 
secreted by the pancreas. The dextrin thus formed 



32 I XF AX TILE DIGESTIOX AXD METABOLISM 

is still further changed into maltose by the same fer- 
ment, after which the further reduction, mentioned 
in the preceding paragraph, takes place. It will be 
seen that, although lactose is, strictly speaking, the 
only normal carbohydrate for the infant, a considerable 
number of allied substances is available for the same 
purposes. 

These various carbohydrates, while capable of 
replacing one another quite well, as far as regards 
caloric value, are by no means exactly equivalent 
with respect to their relation to the digestive functions, 
even aside from the facts already related. Hartje, 
as well as others, notes that lactose particularly favors 
the growth of the bacteria that are most characteristic 
of the flora of the infant intestine, namely, the lactic 
acid bacilli. Nothing is better established than the 
fact that lactic acid fermentation, the acid being 
directly formed by bacterial action from a part of 
the ingested lactose, is essential to the maintenance 
of normal conditions in the intestine; it replaces the 
decomposition and putrefaction that take place in 
the intestinal contents of the adult. Skatol, indol, 
hydrogen sulfid, and similar substances are not found 
in the normal infant's intestine, and are always asso- 
ciated with more or less disturbance, when present 
under pathological conditions. Lactose also keeps 
down the formation of soaps in the intestinal contents 
(Freund 1 ) ; we shall see, in discussing the infant's mineral 
metabolism, that reduced excretion of soaps favors the 
retention of a greater proportion of the important 
element calcium, to the significance of which we shall 



C AUBOIIYDRATE METABOLISM 33 

often have occasion to refer. The precise manner, in 
which the formation of calcium soaps is restricted, is 
still very far from clear, and cannot become so until 
we learn in which chemical combination the intestinal 
absorption of calcium takes place. In close relation 
to the last mentioned function, lactic acid is the physio- 
logical preventive of that bugbear of infant-feeding, 
namely, constipation, which is so difficult to avoid 
when other carbohydrates than lactose are given 
(Calvary 1 ); on the other hand, lactic acid does not, 
like some of the lower fatty acids, tend to promote 
peristalsis and cause diarrhea (Bahrdt and Bamberg). 

Anticipating a little, we may mention that all cases, 
in which lactose may advantageously be replaced by 
other carbohydrates, are pathological, and without 
exception the result of unsuccessful attempts at arti- 
ficial feeding; they will therefore be discussed under 
that head. 

Dextrin, intermediate between sugar and starch, 
is physiologically nearer to the former; we shall have 
occasion to see that, under certain conditions, it 
may supplement sugar very advantageously. Given 
together with maltose, it materially delays the fermen- 
tation of the latter; Stolte 1 observes that the more 
complex the carbohydrate the longer fermentation 
is postponed. 

As might be expected, starch is a relatively undesir- 
able infant food, though it has played a very extensive 
role; whereas most babies take sugar about equally 
well, they differ very widely in their tolerance of starch; 
evidently there are great variations in the diastatic 



34 INFANTILE DIGESTION AND METABOLISM 

function. Starch is usually given as a decoction of 
some cereal, the favorites being oatmeal, barley meal, 
and, in Germany, wheat flour. Most of the advan- 
tages afforded by cereal feeding are due to other factors 
than their starch content. The cereals favor bacterial 
growth far more than do the sugars ; oatmeal distinctly 
fosters the formation of the volatile fatty acids, and 
consequently is decidedly laxative; wheat flour can 
hardly be said to affect peristalsis appreciably; barley 
flour lies in between the two (Klotz, 1 Philips 1 ). Cereal 
feeding leads to a rapid loss of salts (Salge^/a very 
undesirable feature, which is by no means compen- 
sated by the fact that the cereal carbohydrate, namely 
starch, is well utilized if given in moderate quantities 
(Pf ersdorf and Stolte) . We shall presently see that the 
maintenance of the body's salt-equilibrium is one of 
the essentials in successful infant feeding; on the other 
hand, since the absorption of lactose is practically 
perfect in the normal infant, there can only exception- 
ally be any advantage in substituting for it another 
carbohydrate. 

Fats and carbohydrates can, to a certain extent, 
replace each other in the body economy, but this 
mutual compensation has certain well-defined limits. 
The normal food of the infant contains much more 
fat, in proportion to its weight, than is consumed by 
the adult; its carbohydrate intake is somewhat, but 
not decidedly lower. Fat therefore clearly plays an 
exceptionally important part in the metabolism of 
early life; it is not only stored under the skin and else- 
where as a fuel reserve, but it also acts as a conservator 



METABOLISM OF THE SALTS 35 

of the body heat through its low conductivity. Sugar, 
on the other hand, is valuable almost solely as a body 
fuel, and is stored only to a small extent, chiefly in 
the liver, as glycogen. Proteins should not be expected 
to replace either the fats or the carbohydrates, though 
they may also supply body heat in an emergency; 
this function should, however, be kept down to a 
minimum whenever possible, and failure to do so is 
a fundamental dietetic error. When we go on to study 
the caloric requirements of the infant, we shall see 
that they are very much higher than in later life. The 
caloric value of fats is more than twice as great as that 
of the other foodstuffs ; it is evident that the capacity 
to absorb fats is the basis of the infant's well-being, 
and that proteins and carbohydrates, to achieve similar 
results, even from the purely caloric point of view, 
must be given in quantities that are unmanageable 
because of their bulk, aside from other reasons. 



METABOLISM OF THE SALTS. 

According to Camerer and Soldner the body of the 
newborn infant contains 75 grams of salts, of which 
about three-fourths is calcium phosphate, and one- 
tenth each sodium and potassium chlorids; magnesium 
salts amount to somewhat more, and iron compounds 
to somewhat less than 1 per cent. each. Human milk 
contains far more salts, with the exception of iron, 
than are required by the infant, but the supply of 
iron is only just sufficient. We shall see that the 
circumstance that cow's milk contains about four 



3G INFANTILE DIGESTION AND METABOLISM 

times as much mineral matter as human milk, is of 
no advantage whatever to the artificially-fed baby; 
incidentally, the supply of iron in cow's milk is very 
inadequate. 

Sodium chlorid is not absorbed through the intes- 
tinal wall solely in conformity with the local osmotic 
conditions, and is retained in the organism in exactly 
the amount required to keep up the physiological 
concentration. Excessive feeding with sodium chlorid 
is very apt, in the infant, to lead to excessive water 
retention (Freund 2 ); E. Schloss 1 has shown that the 
ingestion of 0.5 to 0.75 gram of sodium chlorid increases 
the body weight from 60 to 120 grams, the gain con- 
sisting wholly of water, which is added practically in 
the physiological ratio. In other words, an excess of 
salt causes an accumulation of water in the blood and 
other tissues in about the proportion of 1 to 120, and 
this takes place the more readily because sodium chlorid 
is excreted only very slowly by the infant kidneys, 
and hardly at all in the feces. 

Potassium chlorid is far less apt to cause disturbance 
of the water equilibrium. E. Schloss 1 has demon- 
strated the relatively rapid elimination of potassium 
chlorid by the kidneys. Theoretically, potassium salts 
are more toxic than sodium salts; clinically, the more 
rapid elimination of the former more than compensates 
for their greater toxicity. 

Freund 2 has shown that the retention of sodium 
chlorid and water is not accompanied by the laying 
on of fat; these two processes are opposed to each 
other, and cannot take place simultaneously. In 



METABOLISM OF THE SALTS 3t 

accord with this arc the findings of Steinitz, who shows 
that high fat feeding tends to lower the assimilation 
of the alkalies, with an increased output of ammonia 
in the urine. 

The absorption and assimilation of calcium present 
a very complicated problem. The absorption of 
calcium from cow's milk, although that element is 
five times as abundant as in human milk, is relatively 
not so good, though quantitatively considerably 
greater; furthermore, the loss of calcium through 
the feces, the main route of elimination, is so many 
times greater in artificial feeding, that the net assimi- 
lation is less than from human milk. The loss occurs 
chiefly in the form of insoluble soaps, formed through 
the binding of the calcium by the undigested cow-milk 
fats in the lower intestine. Hoobler 2 seemed to secure 
better calcium retention with high fat feeding, than 
when he gave mixtures that w r ere low in fat. There 
is reason to believe that this experience w r ill be verified 
by other observers, but as a practical routine measure 
for promoting calcium retention it is open to objec- 
tions that will be discussed more fully under the head 
of artificial feeding. Let it suffice here to say that 
this measure is replete with danger, especially in 
early infancy, as past experience has abundantly 
shown. The recent efforts of Stolte* 2 and others, to 
revive interest in high fat feeding, refer to fat percen- 
tages that, not long ago, w r ould have been regarded as 
inadequate. 

Iron is barely sufficient in human milk, to meet 
the infant's needs; in cow's milk there is a marked 



38 INFANTILE DIGESTION AND METABOLISM 

deficiency, the importance of which will be considered 
later. The conditions of absorption and assimilation 
of iron are very similar to those of calcium. The 
chief need of iron is of course to maintain the hemo- 
globin content of the blood. 

The metabolism of magnesium is so closely allied 
to that of calcium that a separate discussion is hardly 
necessary. 

We have already stated that calcium phosphate 
constitutes about three-fourths of the mineral matter 
of the infant's body; the metabolism of phosphorus 
therefore is of exceedingly great importance and 
interest. First, its absorption and assimilation, as 
might be expected, run closely parallel to those of 
calcium (Schabad 1 ). Secondly, its excretion, which is 
effected chiefly in the urine, is in inverse ratio to the 
loss of fat in the feces; in other words, if the calcium 
is not bound to fatty acids in the intestine, it has 
a better opportunity to combine with the ingested 
phosphorus, and vice versa (J. and W. Cronheim). 
This would make it appear that the retention of phos- 
phorus is less easily interfered with than that of 
calcium, consequently the promotion of calcium 
retention is the crux of the mineral feeding problem. 
Thirdly, we can improve the assimilation of calcium by 
giving phosphorus (Schabad 1 ), but this element must 
be given either uncombined, or in certain protein 
combinations such as casein. Berg has shown that 
phosphorus, in the forms of calcium or other phos- 
phates, as well as glycerophosphates, hypophosphites, 
phytin, and lecithin, is quite useless for this purpose. 



METABOLISM OF THE SALTS - 39 

I need hardly add that the chief function of the absorbed 
calcium and phosphorus is to promote the hone forma- 
tion of the growing infant, though considerable amounts 
are also needed for the development of other tissues, 
especially the central nervous system. 

Knox and Tracy have shown that the excretion of 
phosphorus in the urine is greater in artificial than in 
breast-feeding, but they admit that the nature and 
severity of the nutritional derangement, thus indicated, 
cannot be estimated with any degree of accuracy. 

Sulfur forms less than 1 per cent, of the mineral 
substance of the body and, until Freund 3 began his 
investigations, had been studied very little. Ploobler 2 
finds an absorption of 92 per cent, and an assimilation 
of about 30 per cent, under favorable conditions. 
Elimination takes place mostly through the urine. 
As it is a protein constituent, its functions must be 
of the greatest importance; our knowledge of these, 
however, is so far very inconsiderable. 

The water metabolism of the infant is relatively 
simple; we have seen that it is in a- direct relation 
to the absorption of the alkaline chlorids. More 
water is excreted than absorbed, for a considerable 
quantity is produced in the combustion of the proteins, 
fats, and carbohydrates. A certain minimum of water 
must be ingested, to maintain the normal salt metabo- 
lism; Meyer 1 sets this minimum at 15 per cent, of the 
body weight per day, O. and W. Heubner consider 12.5 
per cent, sufficient and most of the feeding tables pro- 
vide for about 10 per cent., which is probably enough 
under ordinary conditions. Much, quite naturally, 



40 INFANTILE DIGESTION AND METABOLISM 

depends on such matters as the increased respiratory 
loss of water in a very active infant, or the increased 
transpiration through the skin in hot weather, so that 
we cannot set an arbitrary standard. Both Meyer 1 and 
Niemann 1 have observed a tendency of the body weight 
to become stationary or even decline, if insufficient 
water is given. 

The gas metabolism of the infant need not detain 
us long; it differs from that of later life chiefly in its 
greater activity; both the intake of oxygen and the 
output of carbon dioxid are relatively large. The 
latter interests us especially, as being an index of 
the caloric energy of the body, a subject that will be 
taken up presently; otherwise, it presents no features 
that are in any way peculiar to early life. 



GROWTH AND WEIGHT. 

The newborn infant measures about 52 cm. (20.5 
inches) in length, attaining about 61 cm. (24 inches) 
at three months of age, 67 cm. (26.5 inches) at six 
months, 74 cm. (29 inches) at one year, and 82 cm. 
(32 inches) at two years. The normal weight of infants 
is given in the accompanying table. 

Breast-fed babies gain more regularly than bottle- 
fed infants : the latter are more apt to present a zig-zag 
line on the weight-chart, to fall behind during the first 
few months, and to gain rapidly toward the end of 
the first year. The reasons for these deviations from 
the normal will be given later. 



GROWTH AND WEIGHT 1 1 



Weight. 

A,ge. Kilos. Poundt 

At birth 3.3 7\ 

3 days 3.1 63 

1 week 3.2 7 

2 weeks 3.4 7\ 

3 weeks 3.6 8 

1 month 3.8 X.J 

2 months 4.7 10J 

3 months 5.5 12 

4 months G . 2 13§ 

5 months 0.7 14 J 

G months 7.1 15f 

7 months 7.4 16 J 

8 months 7.7 17 

9 months 8.0 17^ 

10 months 8.3 18J 

11 months 8.6 19 

12 months 9.0 20 

15 months 9.7 2\\ 

18 months 10.4 23 

24 months 11.8 26 



Even in successfully breast-fed infants, there is 
an initial loss of weight during the first two to seven — 
average three and a half days, amounting to about 
half a pound; the loss is not regained until the fifth 
to the twenty-second day — average ten days (South- 
worth 1 ) . Many other authors, especially such as refer 
to infants in institutions, give much more unfavorable 
figures, but Southworth's 1 data are quite applicable to 
the children of well-to-do families in private practice. 
In bottle-fed infants, the initial loss is apt to be greater, 
and the recovery slower, so that it often takes a month 
or more to regain the original weight, even with the 
best of management. 

The causes of the early loss of weight have been 
the subject of much speculation, but may now be 
regarded as quite definitely settled. In the first place, 



42 INFANTILE DIGESTION AND METABOLISM 

the infant makes little effort to obtain food during 
the first, and sometimes also the following day 
(Aronstamm). Secondly, along with the deficit in 
the food intake, there is at the same time a shortage 
in the water intake; we have just seen that this is 
sure to involve some loss of weight. Townsend sets 
down a loss of 3 J ounces for meconium, and 1J ounces 
for the vernix caseosa, both items possibly overrated, 
but still not to be entirely ignored. It is not quite 
accurate of Birk 2 to regard the newborn infant's 
balance as adequate, in spite of the decline in weight; 
disregarding the meconium, as composed chiefly of 
detritus, there is no question as to the loss of nitrogen 
and salts in the urine, and of carbon in the expired 
air, the salts being drawn off with the excreted water, 
and the nitrogen and carbon derived from the disin- 
tegration of a certain amount of body protein, fat and 
carbohydrate. In accord with these facts, Cramer 1 
regards the early loss of weight wholly, or at least 
partially, avoidable by early artificial feeding; he 
recognizes, however, the disadvantages and even 
dangers of this procedure, so that it hardly ranks as 
a practical measure. At this point, we may take note 
of what Holt 1 has aptly designated as inanition fever, 
occurring in infants during the period of declining 
weight; he checks this rise of temperature promptly, 
by giving a few ounces of water in the course of the 
day. This simple procedure may very well be adopted, 
both to prevent inanition fever, and to keep the normal 
loss of weight within moderate limits; v. Reuss recom- 
mends it as a routine method. 



CALORIC REQUIREMENT '43 

While too much stress cannot be laid on the body 
weight as a test of the successful feeding of an infant, 
the above discussions will have been wasted, if we follow 
this standard blindly. We shall have ample opportuni- 
ties to study its fallacies, when we come to the con- 
sideration of artificial feeding; for the present it will 
suffice to state that mere regard to the body weight, 
without allowance for the water and salt equilibrium, 
is a fruitful source of error in judging the progress of 
the individual infant. 



CALORIC REQUIREMENT. 

The study of the caloric requirement of the infant 
has, for many years past, engaged a large portion of 
the time and labor of pediatrists; the essential facts 
have, however, been understood for some time, and 
comparatively little of practical value has been added 
by recent investigations. 

Let us begin with a brief sketch of the principles 
involved, and a definition of the terms employed. The 
sum of the work, performed by the body in twenty-four 
hours, is designated as the daily energy output; this 
is measured in large calories, one calorie being the 
quantity of energy required to heat one kilogram of 
water 1° C. The energy output includes two factors: 
(1) the functional metabolism of the body, which 
is roughly proportionate to its bulk, and (2) the main- 
tenance of the body heat, which is proportionate to 
its radiating surface. The former varies enormously, 
according to the infant's muscular activity, mere 



44 INFANTILE DIGESTION AND METABOLISM 

screaming raising it 50 per cent. (Schlossmann and 
Murschhauser). The latter varies chiefly according 
to the surrounding temperature and humidity, as 
modified by the clothing; it may be reduced to zero 
at the indifferent temperature — for infants 80° to 95° 
F., varying with the humidity, and higher in newborn 
than in older infants — or may even become negative, 
with symptoms of heat retention, namely, thermic 
fever (heat-stroke), in very hot weather, or in the 
incubator. In a cool room, or out of doors in ordinary 
weather, the radiation of heat becomes an important 
item, since the head, at least, is always more or less 
exposed, and protection by clothing cannot be made 
perfect. The loss of heat by radiation is relatively 
great in infancy, owing to the proportionately large 
body surface. 

The total number of calories in the daily energy 
output, divided by the weight in kilograms, gives the 
figure called by Rubner the energy quotient. This 
should include the storage of energy, involved in the 
infant's growth, amounting to about 20 calories in 
early infancy, and 10 toward the end of the first year. 
The energy quotient is best stated as the intake, as 
more easily calculated, and the infant's weight regarded 
as the test of whether the output is larger or smaller. 

Allowing for such imperfect absorption and metabo- 
lism, as lie within physiological limits, the net caloric 
value of the different foodstuffs, in large calories, is 
as follows: 

Proteins .... 4 calorics per gram. 120 per ounce 

Fats 9 " "270 

Carbohydrates . . . 4 " " 120 



CALORIC REQUIREMENT 45 

One-half calorie should be deducted for vegetable 
protein, and one for the fat of cow's milk, if we desire 
real accuracy; this is not usually done, so that the 
caloric intake, in artificial feeding, is apt to be some- 
what overestimated. 

The salts — estimated as ash in analysis — have no 
caloric value, and the same is true of the ingested water. 

Caloric estimation is not quite so simple as the 
above data would suggest, and the calculations of 
various observers differ so widely as to create some 
doubt as to their real value. I give a few illustrative 
examples, all expressed as energy quotients. 





First 

three 

months. 


Second 

three 

months. 


Third 

three 

months. 


Fourth 

three 
months. 


Beck 1 . . . 


. . 107 


91 


S3 


69 


Finkelstein 1 


. . 100 


95 




80 


Ladd 2 . . . 


. . 116 


126 


125 


120 


Boissonas 


. . 170 


140 




110 



As a further contrast we may note 63 calories, 
obtained by Schlossmann and Murschhauser in a ten- 
pound infant, 55 to 82 by Calvary 2 in young infants, 
and 70 by Budin and Planchon. Schlossmann and 
Murschhauser admit, however, that their figure applies 
to a very quiet baby, and that a restless or crying 
child gives a larger quotient. Of interest is the obser- 
vation, first made by Cramer 3 and Aronstamm, that 
the energy quotient during the first few days of life 
rarely exceeds 60; Cramer 3 attributes this low figure 
to water retention, which explanation is far from satis- 
factory, as we have seen that there is a considerable 
loss of water at this period. To me the theory of Feer 1 



46 INFANTILE DIGESTION AND METABOLISM 

seems much more reasonable ; he thinks that the energy 
quotient varies according to the food-supply, and that 
the body tissues are economized when this is scanty; 
furthermore, at this time, instead of allowing 20 calories 
for the gain in weight, we may subtract an equal 
amount to represent the physiological loss; in this 
manner the low figures, in the first days after birth, 
seem readily explicable. 

We do well to admit that all the work in this field 
has dealt purely with the theory of nutrition and that 
its arguments have been essentially a priori; the 
actual requirement of the infant is uncertain, variable, 
and probably only vaguely determinable; the idea 
that definite metabolic and nutritional results can be 
obtained from a definite caloric food-estimation has 
hitherto been, and will probably remain chimerical. 
We shall still be compelled to fit the amount of food to 
the physical requirements of the individual infant, 
and not expect to obtain definite results from a fixed 
quantum of ingesta; it is indeed doubtful if caloric 
investigations have been of great practical value 
in determining methods of infant-feeding. Even 
simple mechanical devices, made to resemble one 
another with mathematical precision, will not give 
equal results from equal supplies of energy; still less 
can such exactness be expected from the complicated 
and imperfectly understood mechanism of the human 
body. 

It cannot be said that investigators have been 
unaware of these difficulties. One method of correction 
is to calculate the energy quotient with reference to 



CALORIC REQUIREMENT 47 

the surface of the body instead of its weight; we have 
already seen that both points of view are almost 
equally important. This plan was adopted by some 
of the earliest observers, who laboriously measured 
the body surface with paper strips; it is evident that 
this procedure is too delicate and difficult for every-day 
use, and therefore Meeh, Lissauer, and Rowland and 
Dana have endeavored to draw up simple formulas, 
by which the body area can be deduced from the 
length and weight. The results of these efforts have 
been very varying, and the possible fallacies are only 
too obvious; a ratio between surface and weight is 
gratuitously assumed to exist, without any real proof 
that such is the case. It is therefore evident that this 
modification hardly represents an advance; it is 
merely another unsuccessful attempt to reduce to 
simple figures a matter that is not thus reducible. 
The energy output and the energy quotient must 
be recognized as variable individual characteristics, 
to be considered chiefly as an additional check on the 
feeding methods, that will be described in detail in 
the following chapters. 



CHAPTER II. 

BREAST-FEEDING. 

Human milk, strictly speaking, the mother's milk, 
is the infant's normal food during the greater part of 
the first year. It is therefore desirable to give as 
complete an account, as possible, of human milk and 
its relation to the infant organism, first, because the 
majority of babies are breast-fed, and secondly, because 
breast-feeding is the standard, to which we seek to 
adapt the various methods of artificial feeding. 

COLOSTRUM. 

The earliest secretion of the mother's breast, called 
colostrum, differs materially from true milk; its average 
composition is as follows (Camerer and Soldner) : 



Water 87.9 per cent. 

Proteins 3.1 

Fats 3.3 

Milk-sugar • . 5.3 " 

Salts 0.4 



Colostrum is light yellow in color and decidedly 
alkaline, richer than milk in whey-proteins and salts, 
especially globulin and phosphorus, poorer in casein and 



COLOSTRUM -49 

sugar. The proteins may exeeed G per eent. on the 
first day, and the caloric value 1000 per liter (Lang- 
stein, Rott and Edelstein). Microscopically the charac- 
teristic elements are the so-called colostrum corpuscles, 
which are cellular bodies of several times the diameter 
of leukocytes; there is present, besides, a large number 
of leukocytes. A high proportion of polymorphonuclear 
leukocytes (80 to 90 per cent.) gives promise of an ample 
secretion of milk later (Zuckerkandl) . 

After a few days a change begins to take place in 
the composition of colostrum, as it is gradually replaced 
by true milk; this process is usually complete by the 
twelfth day, but sometimes takes a month (Steele). 
Occasionally we note a partial reversion to colostrum 
characteristics, indicated by a reappearance of colos- 
trum corpuscles; this may be the result of psychical 
shock, returned menses, supervening pregnancy, and 
rarely other causes. It is usually only temporary, 
so that withdrawal of the infant from the breast is 
rarely called for (Spolverini 1 ) . 

It has been determined, by hemolytic tests, that 
the colostrum proteins are, at least in part, derived 
from the blood (Bauer 1 ), whereas the milk proteins 
are entirely the product of the mammary glands. The 
hemolytic and bactericidal powers of the colostrum 
are, however, inconsiderable (Kolff and Noeggerath). 
The fat and sugar of colostrum are identical in kind 
with those of milk (Engel and Bode), but there is an 
excess of oleic acid in the former. The excess of salts is 
possibly responsible for its slightly laxative action, but 
this point is by no means settled. 
4 



50 BREAST-FEEDING 

COMPOSITION OF HUMAN MILK. 

True human milk consists of a serous fluid, holding 
in suspension the fatty milk-globules, and in solution 
proteins, milk-sugar, salts, extractives, and gases; 
cellular elements are scanty in normal milk. Its 
chemical composition is very variable, and ranges 
about as follows: 

Water 87 . to 88 . 5 per cent, 

Casein 1 . 1 to 1 .4 

Lactalbumin and lactoglobulin . . 0.4 to 0.6 

Fats 3 . 5 to 4 . 

Milk-sugar 6 . 5 to 7 . 

Salts 0.2 

Of the salts, potash amounts to about 7 cgm. per 
liter, phosphoric acid 4, lime and ehlorin each 3, 
soda 2 cgm., and oxid of iron 2 mgm. The caloric 
value of human milk ranges between 640 and 720 
calories per liter or quart, 19 and 22 per ounce. 

Not only does the milk of different women vary 
greatly, but the same mother may yield very different 
milk on different days, and this without reference to 
the period of lactation (Sharpies and Darling). Even 
the milk from the two breasts may differ, an important 
thing to remember in raising twins, who should be 
put to both breasts in rotation (Zappert and Jolles). 
The secretion is apt to be more abundant in the morn- 
ing, than later in the day, probably because of the 
accumulation of milk overnight. 

The proportion of proteins and fats is relatively 
low in primiparse (Sharpies and Darling). The fats 
are the most variable constituents of the milk; 



COMPOSITION OF HUMAN MILK 5 1 

compared to cow's milk, there is a relatively high per- 
centage of oleates and palmitates, and a low propor- 
tion of stearates and the volatile fatty acids. The 
total amount of fat is low in the morning, and at the 
commencement of nursing, high in the evening, and 
as the breast is nearly emptied (Engel, 1 Forest); the 
proportion of fat may vary from almost zero to more 
than 13 per cent. (Engel 1 ). 

The proportion of sugar is comparatively constant, 
but somewhat higher in primiparae (Sharpies and 
Darling). It may be as low as 4 or as high as 11 per 
cent. (Schlossmann 2 ), but these extremes are excep- 
tional. 

As to the mineral constituents of human milk, we 
may note that the calcium declines in amount toward 
the end of nursing (Hunaeus), and is also reduced by 
an insufficient intake of lime in the food (Dibbelt). 
It cannot, however, be pushed above the normal 
amount by an increase of lime salts in the mother's 
diet; it is, furthermore, subject to great variations 
and fluctuations, and declines in the later months 
of lactation (Schabad 2 ). The proportion of iron runs 
nearly parallel to that of calcium, the percentage 
may, however, be increased by feeding the mother 
with iron (Bahrdt and Edelstein). 

The percentage of phosphoric acid is in proportion 
to that of casein; it is more closely attached to that 
protein in human milk than in cow's milk, and occurs 
in a larger amount as lecithin (Siegfried). The im- 
portance of the last-named substance has been rated 
very high, because it has been regarded as a valuable 



52 BREAST-FEEDING 

source of phosphorus for the infant; since, however, 
Berg has shown that lecithin-feeding is ineffective for 
the purpose of making up a phosphorus deficiency, 
its value has been rendered somewhat problematical. 

The other mineral constituents of human milk 
present nothing characteristic, but one of the most 
important points of all must, on no account, be omitted, 
namely, that human milk contains only about one- 
fourth as much mineral matter as cow's milk. We 
need here merely take note of this fact; it can be 
discussed more profitably when we consider the com- 
position of cow's milk and its utilization as an infant 
food. 

The ferments in human milk have been studied with 
considerable minuteness. Moro 2 finds that human 
milk exceeds cow's milk in hydrolytic and proteolytic 
ferment, as well as oxydase, lipase, and diastase 
(amylase), but he disagrees with the many authors 
who insist on the great importance of these ferments 
to the infant. Fried jung and Hecht have shown that 
babies thrive about as well when the ferments are 
scanty, as when they are abundant. Spolverini 2 is 
one of those who think the ferments necessary; he 
shows how we can increase the proteolytic ferment 
and the diastase in the milk, by giving the mother 
pancreatin and diastase. We must add that Zaitschek 
could not find the proteolytic ferment, though he 
recognized the abundance of diastase. The absence 
of a glycolytic ferment is generally conceded. 

Kolff and Noeggerath claim that human milk pos- 
sesses no immunizing, hemolytic, or bactericidal 



MILK SECRETION 53 

powers of any consequence; in view of the presence 
of the above named ferments, it is, however, difficult 
to deny it a slight restraining influence on bacterial 
growth. 

MILK SECRETION. 

Various methods of promoting the secretion of milk 
have been tried. Unquestionably, the best way of all is 
the act of nursing (Laisney) ; putting a robust baby to 
the breast may develop an ample flow of milk for the 
benefit of a puny infant whose powers of suction are 
feeble (Wile). The nursing of twins usually results in 
an increased supply of milk, quite sufficient to meet 
the double demand (Laurentius) . In certain cases we 
may successfully promote lactation by means of the 
breast-pump (Helbich). We cannot, on the other 
hand, contrary to the popular belief, increase the secre- 
tion by overfeeding the mother, though a very scanty 
food-supply, as, for example, in a strenuous reduction 
cure, will dimmish the flow (Schkarin, Keller, 2 Malagodi, 
Engel 1 ), and the general physical deterioration called 
hospitalism has the same unfavorable effect (Gener- 
sich). Jaschke 1 increased the milk-supply by means 
of local hyperemia, obtained by Bier's method, and 
Nolf claims to have had good results from the hypo- 
dermic injection of about 10 c.c. of milk. 

Zlocisti and a number of other authors think that 
cotton-seed is of value as a galactagogue. Ott and 
Scott find an increase in the flow of milk, following 
the administration of extracts of the pituitary, pineal 
and thymus glands, and of the corpus luteum. On 



54 BREAST-FEEDING 

the question of malt, as a galactagogue, opinions are 

divided; beer has been used for this purpose from time 
immemorial, but this beverage, in any great quantity, is 
decidedly objectionable, because some of the contained 
alcohol is apt to pass into the milk. Whether the 
malt-extracts have any galactagogue action is still 
doubtful; the results from certain proprietary malt- 
protein compounds, such as malt-tropon, are very 
conflicting (Liepmann, Gewin). A great many French 
and Italian observers recommend aromatic substances, 
especially anise, but their reports are far from con- 
vincing. In short, the mechanical stimulus of suction 
seems still to be the most effective and only reliable 
method of increasing the secretion of the mammary 
glands. 

It is well known that the breasts of the newborn 
infant begin to secrete milk in the first week of life, 
continuing to do so for some weeks or even months. 
This is probably due to the passage through the placenta 
of the hormones that activate the maternal mammary 
gland, the same biochemical process thus taking place 
simultaneously in both mother and child. Accordingly, 
Basch believes that the degree of activity of the infant's 
breasts may be regarded as a fair guide to the pros- 
pective milk production of the mother. 

In conclusion, let us remember that any stimulation 
of the secretion of milk is finally limited by the amount 
of mammary tissue. Thiemich 1 observes that the 
usual maximum is from a liter to a liter and a half per 
day, though two and a half liters may be secreted in 
exceptional instances. 



CAPACITY FOR NURSING 55 

For ii good account of our present information on 
the subject of human milk, sec Talbot 4 , who quotes 
from about 150 articles. 



CAPACITY FOR NURSING. 

How many women can nurse their babies success- 
fully for at least six months? This question is not 
to be answered by statistics of the actual prevalence 
of breast-feeding, for, aside from certain possible but 
doubtful racial peculiarities, there is a host of social 
factors that interfere with the only physiological 
method of rearing infants. Davis' report for the situa- 
tion among the poorer classes of Boston is of interest; 
he finds that of Italian mothers 86 per cent, nurse 
their babies, of Russians 82 per cent., of Irish 77, of 
native i^mericans 64, and of Canadians only 55 per 
cent. This shows a decline, partly in consequence of 
an improvement in social status, but more as the 
result of w T hat might be called racial habit and certain 
complicated economic factors. At first sight, breast- 
feeding would seem more economical than bottle- 
feeding, but under our present labor system, the former 
interferes greatly with the mother's chance of earning 
a livelihood, where this is rendered necessary by the 
family circumstances. These two economic influences 
work in direct antagonism to each other, but in general 
it will be found that in communities where the wife 
stays at home the ratio of breast-feeding is high, 
whereas shop and factory life, on the part of the married 
women, lowers the ratio greatly, sometimes almost to zero. 



5G BREAST-FEEDING 

In the opinion of most hospital and dispensary 
observers the vast majority of mothers are physically 
able to nurse their babies. Jaschke 2 estimates that 
98 per cent, can nurse for a brief period and 91 per 
cent, for several months. Schwarz 2 gives the following 
figures, based on a large material on the East Side of 
Manhattan, New York: 97 per cent, for one month, 
91 for two months, 88 for three months, gradually 
declining to 77 for six, and 68 per cent, for ten months. 
Such favorable statistics can, however, be obtained 
only with the exercise of great perseverance in indi- 
vidual cases, when due attention is also given to social 
conditions. Reuben finds that the milk of many 
mothers deteriorates, or fails altogether, after the 
seventh or eighth month. 

Stuhl briefly summarizes the organic causes of 
difficult nursing under three heads: (1) deficient 
development of the mammary glands; (2) malforma- 
tion of the nipples; (3) a combination of both factors. 
Breasts approaching the virginal type are likely to 
furnish very little milk; a voluminous, pear-shaped, 
and somewhat pendulous gland is usually the most 
efficient; but the very pendulous, flat gland, seen in 
many middle-aged multipara, is less adequate. The 
erect nipple should be fully 1.5 cm. in length and 
about 1 cm. in diameter; smaller nipples are more 
difficult for the infant to take hold of, and some women 
have practically none at all. Stuhl thinks that in most 
cases the mentioned obstacles are only relative, and 
may be overcome by judicious management and 
patience, employing the breast-pump in extreme 



CONTRA-INDICATIONS TO NURSING 57 

cases; many infants can thus be supplied with their 
normal food for a month or two, and even a short period 
of feeding with breast-milk represents a material gain. 

CONTRA-INDICATIONS TO NURSING. 

These may be divided into local and general contra- 
indications, the former including local diseases of 
the breast itself, which are usually only unilateral, 
and therefore not an absolute bar to nursing. 

If the nipples are carefully kept clean and dry during 
the latter months of pregnancy, they are not likely 
to give trouble afterward; if they are neglected, fissures 
are apt to occur; these are not so often of traumatic 
origin, as a manifestation of local eczema, due to lack 
of cleanliness, or maceration by the colostrum. One 
source of trouble is the old custom of frequent attempts 
at nursing on the first and second days after delivery. 
Some physicians encourage nursing from fissured 
nipples, if these are not painful; in my opinion the 
risk of infection is too great to permit this. It is safer 
to keep the child from the affected breast, remove the 
milk with the breast-pump under aseptic precautions, 
and apply silver nitrate and aseptic gauze locally until 
the fissures are entirely healed. 

Mere caking of the breast is no contra-indication; 
in fact, vigorous suction is the best preventive of this 
condition, which is always serious, for combined with 
fissured nipples it is the usual precursor of mastitis. 
In mastitis, of course, nursing is absolutely contra- 
indicated in the interests of both parties. 



58 BREAST-FEEDING 

The withdrawal of the infant, under the above 
conditions, involves the undesirable likelihood of the 
breast drying up, with the consequent deprivation 
of the infant of its natural food. Sometimes, when 
merely fissures are present, this unpleasant result 
may be avoided by using the breast-pump; in the 
case of mastitis, however, the gland is quite certain 
to cease functionating in a very short time. 

Affections of the infant's mouth contra-indicate 
nursing only under very exceptional conditions; breast- 
feeding is the best preventive of infantile stomatitis 
and other local lesions. 

Among general contra-indications, active maternal 
tuberculosis ranks first; this consideration comes up 
very frequently and the contra-indication is absolute. 
The drain of nursing is almost sure to hasten the pro- 
gress of the disease, and there is great danger of infect- 
ing the baby, which is subject to an excessive amount 
of exposure in the intimate act of nursing. It must 
be remembered that the susceptibility to tuberculosis 
at this age is extreme. As to latent tuberculosis of 
the mother, opinions are not quite unanimous, but 
prohibition is advisable in these cases also. It is 
different in the case of a history of healed tuberculosis, 
especially of the bones or glands, or a successfully 
operated affection of the genito-urinary tract; here 
nursing is probably quite safe. Presumably healed 
pulmonary tuberculosis must, however, be regarded 
differently, as we can never be quite certain if this 
lesion is entirely cured, here also, I would interdict 
nursing. 



CONTRA-INDICATIONS TO NURSING 59 

Syphilis presents a many-sided problem. It' the 

mother's luetic; manifestations date back farther 
than a few weeks the infant may be assumed infected, 
and breast-feeding usually affords the only means of 
saving its life, for artificially-fed syphilitic babies do 
badly. If the mother's affection, as rarely happens, 
is so recent that the child may have escaped, it may 
be best to feed the child artificially and take no chance 
of its contracting syphilis; in these cases we must 
exercise our keenest judgment. If the child becomes 
accidentally infected after it is born, say at circum- 
cision, nursing is absolutely contra-indicated. We 
have at present, in the Wassermann test, a reliable 
means of settling doubtful cases. I should like, how- 
ever, to call attention to a recent paper by Lucas, in 
which he shows that it is not necessary for both mother 
and child to react positively, and that both, indeed, 
may react negatively, the father only presenting a 
positive reaction. Here, too, there is abundant occasion 
for the exercise of judgment, when the clinical signs 
of lues are not manifest. 

The role of nephritis as a contra-indication to nursing 
has been the subject of considerable debate. In the 
case of recent eclamptic or uremic attacks there has 
been comparatively little controversy, and Frost has 
shown pretty conclusively that under these conditions 
the milk is toxic. Goodall goes further and forbids 
nursing even with mild nephritis, regarding mere 
albuminuria as a contra-indication; in this he en- 
counters the opposition of, more particularly, the 
Italian observers, among whom Spolverini 3 and 



60 BREAST-FEEDING 

Francioni advise against nursing, only in the presence 
of severe symptoms, disregarding albuminuria alone. 
On the other hand, Mori and Concetti 1 are not quite 
convinced of the safety of this position. The subject 
is evidently one that must be considered according 
to individual circumstances; there certainly are some 
mothers, suffering from a mild type of nephritis, who 
can nurse their babies; in these cases it should not 
be difficult to decide whether or not the infant is 
doing well at the breast. 

A well-compensated valvular heart lesion is certainly 
not a bar to nursing, but the slightest decompensation 
interdicts it absolutely; the attending physician should 
rarely be in doubt as to his decision in the individual 
case. Diseases of the nervous system are to be regarded 
variously. The unfortunate child of an epileptic 
mother is surely sufficiently burdened, without sub- 
mitting it to the risk of physical injury, that maternal 
nursing would involve; with regard to insanity the 
same conditions of course hold true. As to hysteria 
and neuroses of the milder types, the hereditary burden 
of the infant is not increased by taking its mother's 
milk; in these cases nursing is usually advisable. 
Sometimes, however, such a woman is temperamentally 
unfitted to take care of a child, and in that event the 
physician must act accordingly. 

In wasting diseases, such as exophthalmic goitre, 
pernicious anemia, and carcinoma, the supply of breast- 
milk is usually so deficient that the question of nursing 
hardly comes up; when it does arise an adverse decision 
is imperative in the interests of both mother and child. 



CONTRA-INDICATIONS TO NURSING 61 

For obvious reasons the acute infectious diseases 
form a contra-indication to nursing, but as to other 
acute febrile conditions there is some diversity of 
opinion. In general it is best to suspend or discon- 
tinue nursing when the mother's temperature exceeds 
101° or 102° F., as, under these conditions, the milk 
is more than likely to possess toxic qualities and 
disagree with the infant. Subfebrile temperatures 
must be considered according to the individual case; 
the objections to artificial feeding must be carefully 
weighed against the possibly trifling risk to the baby 
if it be kept at the breast; in later infancy, conditions 
are relatively favorable for passing on to bottle-feeding, 
whereas in the earlier months this is to be avoided 
whenever possible. 

Though the return of menstruation, during lactation, 
seems to have an unfavorable effect on the quality 
of the milk, it is, nevertheless, advisable not to dis- 
continue nursing if the infant seems to thrive. Accord- 
ing to Rotch, 5 there is a loss of about 1.5 per cent of 
fat, and an equal gain of protein in the milk, during 
menstruation; Bamberg, on the other hand, claims 
that menstruation does not alter the chemical com- 
position of the milk. Should pregnancy supervene 
the milk often ceases to flow, so that nursing ceases 
automatically; should, however, the supply of milk 
continue the same rule applies as for returned men- 
struation; some babies of pregnant mothers do very 
well at the breast, especially during the earlier period 
of gestation. 

Of all the reasons given for discontinuing nursing 



62 BREAST-FEEDING 

the most frequent is the plea that the milk lacks the 
proper nutritive value, or is insufficient in quantity. 
This argument should never be even considered as 
a bar to nursing, unless the child evidently fails to 
gain in weight for several weeks, and, in that event 
also, we should proceed cautiously. Mother's milk, 
that is well below the standard in quality, is neverthe- 
less, as a rule, better for the infant than cow's milk, 
at least during the first few months. The physician 
should not let himself be misled, by a single analysis, 
to consider the milk inadequate; as a matter of fact, 
some babies get along fairly well on human milk which, 
on analysis, seems absurdly insufficient in nourishing 
qualities. This is, after all, not so remarkable, since 
the deficiency is usually in the fats, the least essential of 
the organic constituents; these may, as we have seen, 
be largely compensated by an adequate supply of 
milk-sugar, which hardly ever fails to be present in 
sufficient quantity. Quantitative insufficiency of the 
milk, as a whole, is a more serious matter, and usually 
ends, within a few weeks, in the unavoidable abandon- 
ment of breast-feeding; our statistics have, however, 
shown, that this unpleasant eventuality is not so much 
to be apprehended in the earlier months of lactation, 
as is generally believed both by physicians and the 
laity; later on, if rendered necessary, the change to 
bottle-feeding is a relatively harmless procedure. 

The milk is regarded as flowing freely, if it exudes 
in numerous drops, when the breast is grasped with 
the hand, and pressed gently but firmly; after lactation 
is well established, and the supply is ample, the milk 



CHEMICAL TESTS '63 

fairly squirts from the ducts. A drop of the milk, 
seen by reflected light, should be of a delicate bluish- 
white color, but neither yellowish nor greenish. 

Chemical Tests. — The most practical test for fat 
is Lewi's modification of the Babcock test, which 
requires special but not complicated apparatus, and 
is performed as follows: 

1. Place in the flask 2.92 c.c. of milk as measured 
in the special pipette. 

2. Rinse the pipette thoroughly. 

3. Add gradually an equal quantity of chemically 
pure sulfuric acid, mixing with the milk by gently 
rotating the flask; the color changes to dark brown 
through oxidation of the sugar. 

4. Add 0.6 c.c. of equal parts of amyl alcohol and 
strong hydrochloric acid. 

5. Add 50 per cent, sulfuric acid in sufficient quan- 
tity to bring the fluid up to the neck of the flask. 

6. Centrifuge three or four minutes. 

7. Read off on scale; each 0.1 on the scale repre- 
sents 0.3 per cent, of fat. 

In giving this test in full, we must not fail to note 
what is generally omitted, namely, that extreme 
caution should be exercised in adding the pure sulfuric 
acid, and afterward in diluting the same acid with 
water to a 50 per cent, solution; the acid should always 
be added gradually to the other fluid, otherwise great 
heat is produced, resulting in possible accidents, or 
at least impairment of the value of the test. 

The best test for the proteins, Kjeldahl's, is not 
at the command of the ordinary practitioner. Koplik 1 



G4 BREAST-FEEDING 

recommends a modified Esbach test as proposed by 
"Woodward. Two milk burettes, each containing 5 
c.c. of milk, are allowed to stand over night at a tem- 
perature of 100° F. They are then cooled. The milk 
is drawn off into two Esbach tubes and 10 c.c. of the 
Esbach reagent are added. The tubes are then shaken, 
and centrifuged until the reading is constant. This 
test registers the total proteins. 

The percentage of milk-sugar is so constant as 
practically never to require quantitative testing. 

RULES FOR BREAST-FEEDING. 

The nursing mother should lead a quiet and regular 
life, avoiding social diversions that involve late hours, 
especially if housework is demanding a great deal of 
her attention. We have seen that the nature of her 
diet affects her milk only slightly, if at all, provided 
that it is sufficient; in case of great poverty there 
may be some difficulty on this score, and the relief 
of nursing mothers is one of the worthiest charities. 
Regular and moderate exercise is beneficial, helping 
to avoid one of the great difficulties often attending 
this period, namely, constipation. This ailment is 
best relieved by giving such mildly laxative foods as 
Graham bread, oatmeal, and prunes, but we need not 
hesitate to give a harmless drug like cascara sagrada, 
in sufficient dosage, should medication be unavoidable. 
Alcohol, except in very small quantities, is objection- 
able, but a glass or two of beer per day will hardly be 
injurious, and is recommended by some as a mild 



RULES FOR BREAST-FEEDING 65 

galactagogue. Water and milk should be taken quite 
freely, still not in such quantities as to impair the 
appetite for substantial food. With regard to tea and 
coffee, great moderation is advisable; excessive tea- 
drinking is almost as vicious a habit as the excessive 
consumption of alcohol. 

In giving medicines for intercurrent affections we 
should exercise great care, for many common drugs 
pass into the milk, and thereby affect the child. Dom- 
browsky found this to be the case with most aromatics, 
formaldehyde, phenol, turpentine, and iodoform, to 
which we may add bromin, iodin, the alkaloids, and 
to a slight extent mercury, salicylic acid, and alcohol 
(Voltz). 

I have already called attention to the desirability 
of the four-hour feeding interval, but may, at this 
point, go a little more into details. The old custom 
of tormenting the mother, on the first day after delivery, 
by frequently putting the infant to the breast, is 
happily, though rather slowly, being done away with; 
it is useless to try to nurse the baby on the first day, 
as it cannot suck effectively in any event; we may 
give it a few spoonfuls of water, as previously suggested. 
Twenty-four hours after birth we may begin with the 
regular four-hour schedule, beginning at 6 a.m. and 
ending at 10 p.m. Night-feeding is usually unneces- 
sary, is largely based on tradition, a great hardship 
to the mother, and of doubtful benefit to the baby; 
it is pleasing to record that it is gradually being aban- 
doned. Thus the infant obtains five meals per day, 
which experience has shown to be usually sufficient. 
5 



66 BREAST-FEEDING 

There are some cases, however, in which the infant 
seems to draw a somewhat inadequate supply, and 
the stomach is empty before the expiration of two 
hours and a half. Rosenstern 1 thinks that, in this 
event, we may safely make a slight concession and 
nurse the baby at three-hour intervals, six or seven 
times a day; another plan would be to give a night 
feeding at 2 a.m., during the first few months, but 
Rosenstern's method seems to me the better of the 
two. 

The duration of each feeding is usually set at twenty 
minutes, but this rule is arbitrary and not justified 
by the physiological facts, for Feer 1 has shown that 
most of the meal is ingested in the first few minutes. 
A better plan is to observe the baby during nursing 
and to take it from the breast as soon as it ceases to 
suck actively; this method has the additional advan- 
tage of giving us a fair index of the milk-supply. If 
the baby draws only a short time, the nipple being in 
normal condition, there is reason to suspect a scanty 
flow of milk; on the other hand a vigorous infant may 
easily empty a full breast in ten minutes and then stop 
sucking, being perfectly satisfied; in this case there 
can be no object in keeping it any longer at the breast, 
to fall asleep there. 

I have referred to the prophylaxis of fissured nipples, 
consisting in keeping them clean and dry; the best 
method is to wash them daily with a saturated solution 
of boric acid and dry them gently with sterile gauze. 
This procedure should be begun some months before 
delivery, and at the same time the development of 



RULES FOR BREAST-FEEDING 67 

badly formed nipples may be aided by daily gentle 
traction and manipulation, best performed by the 
prospective mother herself. After delivery, similar 
cleansing should take place after each nursing, and 
the nipples be protected from the clothing by small 
pads of sterile gauze. Should a fissure appear in spite 
of these precautions it should be treated with silver 
nitrate and the child temporarily restricted to the 
unaffected breast; in this way the development of 
a mammary abscess may usually be avoided. The 
unused breast is apt to cake from the stagnation of 
milk; for the relief of this condition we must resort 
to pumping and gentle massage to keep the breast 
from going dry, the caking under control, and to guard 
against inflammation of the affected gland. The 
difficulties just referred to are especially likely to occur 
at the very commencement of lactation, and in primi- 
parse. 

In regard to the care of the infant's mouth a revolu- 
tion in practice has taken place in recent years; the 
rule now reads: let the baby's mouth alone. We 
have repeatedly observed the erosions on the palate, 
called Bednar's aphthae, in infants whose mouths were 
regularly and conscientiously rubbed after each meal 
with solutions of borax or boric acid. The healthy 
breast-fed baby has a mouth that keeps itself quite 
clean enough; the surest way to infect it is to rub off 
the protecting epithelium by unnecessary attempts 
at cleansing. Pacifiers and teething-rings are simply 
abominations; they cannot be kept clean, and are 
used by the infant to convev dirt of everv kind into 



68 BREAST-FEEDING 

its mouth. We might, in this connection, call atten- 
tion to the belief of Pedley, that the continued use 
of the rubber pacifier leads to deformity of the jaws; 
while this is open to doubt, the other objection, referring 
to the extreme dirtiness of this popular infant sedative, 
cannot very well be challenged. In passing we may 
mention, as other means of infecting a healthy mouth, 
the performance of unnecessary operations on the 
frenum lingua? and the edge of the gums, both still 
too frequently practised by physicians of repute. 
Let us remember that true tongue-tie, sufficiently 
severe to interfere with nursing, is quite a rare condi- 
tion, and that the eruption of the teeth is a physiolo- 
gical process, which may give rise to some slight dis- 
comfort and irritability, but is never the cause of 
actual illness. Among the hundreds of infants brought 
to me with the home-made diagnosis of teething, I 
have never failed to find some disturbance of the 
digestive or respiratory tract to account for the 
symptoms present. 

DIFFICULTIES IN BREAST-FEEDING. 

The principal and most frequent error committed 
in the nursing of infants is overfeeding, usually accom- 
plished by adhering to the old tradition of nursing 
at very frequent intervals, of two hours or even less. 
Sometimes the anxious mother nurses the baby when- 
ever it cries, thinking that it cries from hunger; as 
overfeeding leads to intestinal colic, which causes 
the infant to scream loudlv, it is evident that a vicious 



DIFFICULTIES IN BREAST FEEDING 69 

circle is easily established. Nevertheless, overfed 
nurslings usually thrive tolerably well, in marked 
contrast to overfed bottle-babies, but they do not 
gain in weight in proportion to their intake, and regu- 
larly suffer from moderate diarrhea, with three or 
more rather thin and often green stools daily. If 
a robust, breast-fed child has more than two or three 
intestinal movements daily we may safely make a 
tentative diagnosis of overfeeding and investigate 
the case accordingly. These babies constitute the 
majority of partial failures in breast-feeding; in my 
dispensary service at least one-half of all the breast-fed 
infants present the above picture, though we must 
remember that babies who are really thriving are not 
brought to the dispensary at all, so that the true ratio 
is probably much less. These infants improve rapidly, 
and their diarrhea and colic cease within a week or 
two if the feeding interval is lengthened to four hours, 
and the invariably present night-nursing cut out. It 
is often useful, though rarely necessary, to precede this 
change of regime with a dose of castor oil, and a twenty- 
four-hour period of starvation, in which only water 
may be given, so as to give the overloaded and over- 
worked intestine a cleansing and a brief period of rest. 
More serious is underfeeding. In mild cases, due 
to a moderate insufficiency of the milk as a whole or 
the milk fats, the prominent symptoms are constipa- 
tion and a rather slow gain in weight. These infants 
are best kept at the breast, for the first months at 
least; they are not likely to do much better on artificial 
feeding, and may not do as well. A few teaspoonfuls 



I 



70 BREAST-FEEDING 

of oatmeal water, given before each nursing, may aid 
to keep the bowels moving; if this is insufficient we 
may give an occasional small dose of castor oil. The 
administration of calomel or, still worse, rhubarb is 
altogether out of place in this condition. In some of 
these cases the three-hour interval, before noted, may 
be tried. I doubt if the results are worth mentioning, 
and personally have seen no benefit therefrom. 

When the mother's milk supply is seriously deficient 
there is little or no gain in weight, and sometimes even 
a loss; the infant cries almost continually and passes 
small, dark green stools, with some mucus; these are 
the so-called hunger-stools, consisting largely of intes- 
tinal detritus and bacteria, with a relatively small 
proportion of the end-products of milk digestion. 
Under these circumstances we must usually resort to 
artificial feeding; but in the first month of infancy, 
if the starvation is not severe and there is ever so slight 
a gain in weight, we do well not to be discouraged too 
soon. Breasts that secrete poorly at first may even- 
tually furnish a moderately good supply of milk, for 
at any rate a few months, thus tiding the infant over 
the most critical period. Wile observes that sometimes 
the breast may be induced to afford sufficient milk, 
after several weeks of forced suspension of function; 
similarly a gland that begins poorly, especially in a very 
young mother, may become, with patient stimulation by 
means of regular application of the infant, a very fair 
purveyor of nourishment. 

If a baby seems to obtain sufficient food and yet 
manifests a deranged condition of its digestive appa- 



DIFFICULTIES IN BREAST FEEDING ' 71 

ratus, as if its diet disagreed with it, the trouble may 
be with the quality of the milk, but is more likely 
to lie with the child itself. This is, indeed, the clinical 
picture of what Czerny 2 first described as the exudative 
diathesis, which we shall discuss at length in a later 
chapter. At this point we merely wish to emphasize 
what was urged by Czerny 2 himself, namely, that slowly 
as these infants get along on breast-milk they invari- 
ably do worse on artificial food; in short, the only 
safe procedure is to keep the child at the breast at 
all hazards, regardless of the fact that it is not doing 
as well as might be desired. As to inferior quality 
of the breast-milk, we have seen that this factor is 
not easily determinable and often doubtful. We 
may, in some cases, manage to make out a serious 
defect through our physical and chemical examination; 
at other times, however, we may be dealing w T ith some 
obscure constitutional disturbance of the mother, 
manifesting itself in the milk, but defying determina- 
tion by laboratory methods. 

The social difficulties in the way of breast-feeding 
play a great role, but may eventually be obviated, or 
at least reduced from their present wide scope, if the 
public at large will give the medical profession a help- 
ing hand. In recent years it is pleasing to note that 
society women, after decades of almost total neglect 
of the first duty of motherhood, are beginning to 
realize the proper state of things, so that breast-feeding 
is gaining ground rapidly in the higher walks of life. 
The longer feeding interval, combined with the eight- 
hour rest at night, is doing much, and will do more, 



72 BREAST-FEEDING 

to make maternal nursing popular and even fashion- 
able. Among the working classes the situation is 
more difficult, and can be saved only by the general 
acceptance of the long feeding interval; it must also 
be fostered by appropriate legislation on the subject 
of female labor, in which France has led the way, and 
most of the United States lag far in the rear. Much 
was expected of cash nursing-premiums in France 
and Germany; their value has been questioned in 
the countries of their adoption, and Herrman earnestly 
warns us against experimenting with this social placebo. 
Far better is a medically controlled system of education 
by visiting nurses, now being tried out on a fairly 
extensive scale in some American cities. Some 
maternity hospitals are doing excellent work in follow- 
ing up discharged infants and encouraging their mothers 
to keep them at the breast. These measures cannot, 
however, be more than palliative, unless suitable labor 
legislation actually puts a premium on nursing by 
making it economical; if this is done there is not the 
least doubt that the majority of mothers will prefer 
it and artificial feeding will drop from its present 
prominence to a secondary position. 

WET-NURSING. 

\Yhen the mother is physically debarred from nursing 
her infant, a good wet-nurse should afford a fairly 
adequate substitute; unfortunately, in this country, 
a good wet-nurse is a vara avis, in fact, nearly unob- 
tainable outside of our largest cities. We have no 



WET-NURSIXC 73 

sturdy peasantry to draw upon, as is the ease in many 
parts of Europe. Our prospective wet-nurses are 
chiefly drawn from the very dregs of the city slums, 
are unfit to dwell under the same roof with decent 
people, and relatively often diseased. These circum- 
stances have led most American practitioners to advise 
against the employment of wet-nurses, except when 
absolutely unavoidable. 

In selecting a wet-nurse, one desideratum is that 
her delivery shall not have preceded the birth of the 
prospective nursling more than a few weeks, or a month 
or two at the most ; the milk secreted during advanced 
lactation is likely to be too rich for the newborn infant 
and lead to indigestion. It is, furthermore, important 
that she should yield an ample quantity of good milk; 
this may be readily determined by a careful examina- 
tion of herself, and inspection of her own infant, the 
condition of the latter being a good index of the pros- 
pective milk-supply. It is indeed inadvisable to engage 
a w r et-nurse who cannot show a robust baby of her 
ow T n. The third requirement is a searching investiga- 
tion of the nurse's health, with special reference to 
the absence of syphilis and tuberculosis. As to syphilis, 
in addition to the examination for luetic stigmata 
of mother and child, we have in the Wassermann test 
as good a criterion as could be desired if it is made 
by an expert and interpreted in connection with the 
physical findings; the loss of time involved in the 
performance of this test is amply compensated by its 
trustworthiness. As to tuberculosis we are still chiefly 
dependent on physical examination, which is not 



74 BREAST-FEEDING 

absolutely conclusive, and we must be largely guided 
by the woman's general condition. The v. Pirquet 
test is a little too delicate for our purpose, as it reacts 
positively to long since healed tuberculosis, as well 
as to the non-infectious glandular forms of the disease. 
Many possibly eligible wet-nurses cannot meet this 
exceeding searching test, which would make the final 
selection of a suitable person difficult if not impossible. 
At the same time a negative v. Pirquet reaction is 
a good guarantee of the absence of even latent tuber- 
culosis, and therefore unquestionably of the greatest 
value. 

PRESERVED BREAST-MILK. 

Certain foreign authorities, in close touch with 
large maternity hospitals, have suggested the preser- 
vation of surplus breast-milk for the benefit of babies 
whose mothers are unable to nurse. To preserve 
milk, Budde takes advantage of the catalytic ferment 
present in fresh human milk, to split hydrogen peroxid 
and sterilize the milk with the nascent oxygen. Budde's 
method is carried out as follows. After neutralizing 
a liter (quart) of milk with sodium bicarbonate, which 
may even be in slight excess, he adds 0.5 gram (8 
minims) of a 30 per cent. (100 volume) solution of 
hydrogen peroxid, the best preparation being the one 
sold under the name of Perhydrol. The mixture is 
then warmed to 55° C. (131° F.), so as to liberate 
nascent oxygen freely. Milk thus treated will keep 
perfectly fresh for twenty-four hours, when the pro- 
cedure must be repeated. Peiser 1 has thus managed to 



PRESERVED BREAST-MILK 7.") 

preserve milk for as long as fifty-two days. Mayer- 
hofer and Pribram recommend this method highly, 
and it certainly seems well worth trying, whenever 
a non-nursing mother can get into communication 
with another woman who has a surplus of milk at 
disposal. One conspicuous advantage is that it obviates 
the necessity of the wet-nurse abandoning the breast- 
feeding of her own child; another is, that the donor 
can remain in her own home; the third lies in the 
availability of a higher grade of wet-nurse; the fourth 
is the circumstance, that the milk can be transported 
a considerable distance. 

The milk must, of course, be drawn with a pump 
and fed from a bottle; this means that all the rules 
of cleanliness must be enforced that are required with 
the handling and feeding of cow's milk. Under these 
conditions the plan here outlined will often be invalu- 
able, and there are many cases in which it can be 
tried before resorting to the last refuge of feeding with 
cow's milk. Hoobler 3 is the most recent advocate of 
the collection of surplus human milk for use in hos- 
pitals and dispensaries, and the peroxid method should 
be a valuable aid in the successful accomplishment of 
this purpose. 



CHAPTER III. 
COW'S MILK. 

Practically the only available substitute for 
human milk is cow's milk. In some countries the 
milk of other animals has been given to infants, bu tin 
America the cow is the one prevailing source of supply. 

Cow's milk is a faintly acid fluid, of a yellowish- 
white color, that separates, on standing, into two 
layers. Within four to eight hours these layers are 
sharply defined, the upper very opaque, of a decided 
"creamy" yellow tint, containing nearly all the fat, 
and the lower translucent, bluish white, and nearly 
fat-free. The depth of the upper layer is more or 
less proportionate to the percentage of fat in the milk. 

Milk is sometimes turned blue by the Bacillus cya- 
nogenes (Hammer); this alteration appears to be 
harmless. 

Composition. — The composition of milk obtained from 
Holstein or "grade" cows ranges about as follows: 

Water 87.0 to 88.0 per cent. 

Proteins 3.0 to 3.5 

Fats 3.5 to 4.0 

Milk-sugar 4.5 " 

Salts 0.75 " 

The total caloric value of ordinary cow's milk ranges 
from 620 to 680 per liter (quart), or 19 to 21 per ounce, 
practically the same as of human milk. Clinically 



ANALYSIS OF COW'S MILK 77 

the inferior digestibility of cow's milk calls for a reduc- 
tion from the above estimate of about 30 calories per 
liter, or 1 per ounce. 

Cows of the Guernsey or Jersey breeds give a far 
richer milk, with 4 per cent, of proteins, 5.5 or more 
of fats, and 5 of sugar, a caloric value of 850 or more 
to the quart, 25 or more to the ounce. 

It will be seen that the proteins are far more abundant 
than in human milk, the carbohydrates about as 
much less, and the fats about the same. The salts 
are nearly four times as abundant, and are divided 
about as follows (Pelka) : 

Phosphoric acid 0.21 per cent. 

Lime 0.15 

Potash 0.18 

Soda 0.10 

Chlorin 0.11 

Iron (as oxid) 0.3 to 0.7 mg. per liter 

It will be seen that iron forms an exception and is 
considerably scantier than in human milk (Langstein 1 ) . 

Van Slyke calls attention to the fact that the salt 
estimates do not allow for the salts of the organic 
acids, which would raise the total salt percentage to 
0.9; this happens because the salts are always calcu- 
lated as ash, and the organic acids become converted 
into carbon dioxid, which escapes during incineration. 

Of minor but still not negligible importance are 
the ferments, and the greatest possible interest attaches 
to the bacteria found in cow's milk. 

Analysis of Cow's Milk. — The fats may be estimated 
by the method given for human milk. Bowditch and 
Bosworth obtain a complete analysis in the following 



78 COW'S MILK 

simple manner, and have found the results, thus cal- 
culated, sufficiently accurate for all practical purposes: 
Let L = the reading of the Quevenne lactometer 
(specific gravity — 1000) and let F = the percentage 
of fat: Then 

L + (1.2 X F) = total solids. 
4 

L + (0.2 X F) = solids not fat. 
4 

(F - 3) X 4 + 2.1 = casein. 
(F - 3) X 4 + 2.8 = total proteins. 
Total solids — (F + total proteins + 0.9) = sugar, (0.9 is added 
to allow for the salts). 

The Proteins. — Most authorities calculate the casein 
as about three-fourths of the total proteins and lactal- 
bumin and lactoglobulin, the so-called whey-proteins 
as one-fourth. Grulee 1 thinks that the latter have been 
overestimated and rates them as only one-sixth or 
even less. This difference he attributes to inaccuracy 
in analytic methods, inasmuch as most investigators 
do not coagulate the casein perfectly, so that some 
of this protein drains off into the whey, and is erro- 
neously estimated as lactalbumin. A few, years ago 
this diversity of opinion would have been regarded 
as of some moment; in the present state of our know- 
ledge as to the assimilation of the proteins, the matter 
may be considered of minor and perhaps only academic 
importance. 

Until quite recently the casein of cow's milk was 
almost universally regarded as less digestible than 
human casein, and this belief was based on the follow- 
ing observations: (1) cow's milk contains about twice 
as much casein as human milk; a priori, it would seem 



THE PROTEINS 79 

that the former would be apt to overburden the infant 
with this protein, even if somewhat diluted with water; 
(2) it was noticed that cow-milk casein coagulated 
in the baby's stomach in large, hard masses, whereas 
human casein formed delicate flocculi; this was attrib- 
uted to a chemical difference between the two forms 
of casein, which appeared well established by the 
investigations of Siegfried and others, but, as a 
matter of fact, is not absolutely proven. Alexander 
and Bullowa give a purely physical explanation for 
the difference in coagulation; they call attention to 
the fact that casein is an unstable colloid, protected 
by lactalbumin, and that this protection is more 
effective in human milk, which contains a far larger 
proportion of the latter proteid; for the same reason 
the human casein naturally occurs in a much finer 
state of subdivision, and therefore forms a more 
delicate coagulum, when attacked by the rennin of 
the infant's stomach. There is no reason to doubt 
the accuracy of these observations, and we are forced 
to admit that the coarse coagula of cow's-milk casein 
are more difficult of digestion. This disadvantage 
may, however, be avoided if we follow the advice of 
these authors, which merely repeats the recommen- 
dations of a past generation. If we protect the cow's- 
milk casein artificially, by the addition of a mucila- 
ginous fluid like barley-water, the coagulation of this 
substance is rendered very similar to that of human 
casein, and the formation of large unmanageable 
masses is effectively checked. We may add that 
Langstein 2 has shown that human and bovine casein 



80 COW'S MILK 

are peptonized exactly alike by the infant's digestive 
secretions. 

In this connection we may well devote a paragraph 
to the subject of casein curds in the stools. Some 
years ago all more or less white lumps and particles 
in the feces were called curds by American prac- 
titioners, though the term curds is properly applied 
only to coagula of casein or, at most, proteins. Mean- 
while many foreign observers claimed that casein 
coagula never occurred in the feces, and that the white 
particles referred to were composed almost wholly of 
fats and fat derivatives. A brisk discussion ensued: 
Talbot 2 3 represented the faction, chiefly American, 
who insisted on the frequent presence of true casein 
in the feces, whereas the opposition, chiefly German, 
who denied the occurrence of true curds in toto, were 
represented in American pediatric literature by an 
article by Meyer and Leopold aside from many trans- 
atlantic contributions. Southworth and Schloss tried 
to take up an intermediate position by admitting that 
some fat was mechanically included in the casein 
curds, a useless concession of a recognized fact, which 
did not touch the main issue. Finally, Brennemann 1 
showed conclusively that the two parties had been 
discussing two entirely different things; that the small, 
soft, yellowish particles, referred to by the German 
school, but quite as well known here, were not really 
curds at all but actually fatty bodies; on the other 
hand, the large, hard, grayish-white concretions, 
discussed by Talbot, well known here, but almost 
unknown in Germany, were true casein curds, con- 



THE PROTEINS XI 

taining a large proportion of fats, as curds derived 
from whole milk invariably do. Talbot's contention 
is now admitted to be correct by a number of German 
observers, for example, Bauer 2 and Ibrahim, 2 who 
acknowledge that the hard curds consist chiefly of 
undigested casein. As to the cause of their appear- 
ance in the stools, Brennemann 1 claims that they follow 
the ingestion of unmodified or merely diluted raw 
milk, thus bringing the subject in close relation to 
the discussion in the preceding paragraph. They are 
rather rarely observed in Germany, because the Ger- 
mans seldom feed babies on raw milk. As to their 
real importance, Brennemann rates it low, but thinks 
that they may cause some slight intestinal disturbance; 
they undoubtedly represent a loss to the infant of a 
certain proportion of the food proteins, and are objec- 
tionable on that account, if no other; at any rate 
they are usually avoidable by simple measures, the 
adoption of which I think advisable, and which shall 
be taken up under the head of milk modification. 

The whey proteins, lactalbumin and lactoglobulin, 
are also digested about as well from cow's milk as 
from human milk. A few years ago this fact was 
seriously doubted, but this doubt rested on a mis- 
apprehension regarding certain experiments with 
whey-feeding. Meyer 2 disposed of this question by 
proving that any trouble with whey-feeding could 
not be attributed to the proteins, and recent investi- 
gators, such as Bickel and Roeder, are satisfied that 
the whey proteins of cow's milk are a perfectly digestible 
infant food. 
6 



82 COW'S MILK 

Summing up, we see that the absorption of the cow- 
milk proteins is little, if at all, inferior to that of the 
proteins of human milk; in other words, it is nearly 
perfect. The high percentage noted on page 23 was 
obtained with artificial feeding, and it is hard to see 
any room for improvement. 

The Fats. — The chief difference between the fats 
of human and of cow's milk is the excess of oleates in 
the former, and the high ratio of volatile fatty acids 
in the latter; the volatile fatty acids, especially butyric 
acid, are six to eight times as abundant as in human 
milk (Stern). These acids, if they exceed a small 
amount, are, as we have seen, irritating to the infant's 
intestine; they are, moreover, readily converted into 
bodies of the acetone group, the toxic action of which 
will be referred to later. In observing that the fats 
cause the most serious difficulties in the substitution 
of cow's milk for human milk, we must not forget that 
the newborn calf is about as far advanced in develop- 
ment as an infant aged nine to twelve months. Now 
babies of that age rarely have any trouble in digesting 
cow's milk; it is, in fact, their usual and staple food, 
and they thrive on it exceedingly well. In the case 
of young infants, on the other hand, it is evident that 
cow's milk is a rather unsuitable food, and the greatest 
difficulty is probably afforded by the volatile fatty 
acids. Even though these acids amount to only 3.5 to 4 
grams per liter, this represents an excess of fully 3 
grams over the amount in human milk, and cannot be 
an indifferent matter in view of what has been said. 
The differences between the two kinds of milk, as 



THE FATS 83 

regards the other fatty bodies, are so mueh less in 
degree and kind that they probably play a minor 
part. 

Bahrdt has shown that even in infants who take 
kindly to cow's milk the ratio absorbed is only about 
83 per cent.; this is at least 10 per cent, less than the 
proportion absorbed from human milk, and represents 
a deficit of about one calorie per ounce. This unab- 
sorbed fat combines with the milk calcium to form 
the calcium soaps, which make up so large a part of 
the feces of artificially fed infants. It is true that 
cow's milk contains a considerable surplus of calcium 
which is not needed; it is, however, not alone this 
surplus that is bound by the free fatty acids, but 
part of the calcium required for the body's growth is 
also lost in this way. The deficit in fat has therefore 
added to it the still more serious deficit in lime salts, 
which does not appear in the caloric calculations, but 
is of far greater influence on the infant's ultimate 
welfare. 

The disadvantages, so far recorded, are still within 
what may be called physiological limits, though cer- 
tainly not perfectly normal; the succeeding chapters 
will show that these limits are easily passed, and that 
the line between what is physiological and what is 
pathological is not easily drawn in artificial feeding. 

The Carbohydrates. — The lactose of cow's milk is 
chemically identical with that of human milk; its 
digestion and assimilation should not, therefore, 
present any differences. As a matter of fact the assimi- 
lation of sugar is often disturbed in artificial feeding, 



84 COW'S MILK 

but this is invariably secondary to some other digestive 
derangement so far as milk-sugar is concerned. As 
to the digestion of other carbohydrates, much used 
in milk-modification, we need not concern ourselves 
at this point, in discussing the properties of pure cow's 
milk. 

The Salts. — Sodium and potassium chlorids are 
respectively five and two and a half times as abundant 
in cow's milk as in human milk. They are absorbed 
in somewhat smaller ratio, but in acutally larger 
amounts, so that there is a tendency to overload the 
organism with both potassium and sodium salts; 
there is, therefore, a markedly greater excretion of 
both, especially through the urine, in bottle-fed than 
in breast-fed babies. Under normal conditions this 
is of comparatively little consequence, but under 
pathological conditions the metabolism, especially 
of sodium, may become a serious matter; we shall 
have occasion to study clinical pictures in which the 
absorption and assimilation of these large amounts 
of salt play a very important role. 

We have referred particularly to the part played 
by the sodium salts, because the potassium salts are 
supplied by cow's milk in a more moderate ratio and 
the elimination of any excess is effected more easily 
and rapidly. As a matter of experience, potassium- 
poisoning plays a small part in infant pathology, with 
the doubtful exception of certain metabolic disturb- 
ances, such as scurvy, where the role of potassium is not 
proved and most likely negative, as will appear later. 

We have already discussed the main points of calcium 



THE SALTS 85 

metabolism in connection with the fats; its relation 
to the metabolism of phosphorus is equally important. 
The total of phosphorus is five times as great in cow's 
milk as in human milk, and while its rate of absorption 
lags somewhat behind, it still remains much greater 
from the former. It is quite a different matter, when 
we turn to the retention of phosphorus. Keller 1 has 
shown that the only assimilable forms of phosphorus, 
namely, the nucleophosphides, equal 40 per cent, 
of the total in human milk, and only 6 per cent, in 
cow's milk, so that the amount of organic and available 
phosphorus per liter of human milk is actually greater, 
0.16 gram against 0.12. We have seen that inorganic 
phosphorus, as in calcium phosphate, is not capable 
of assimilation. Thus the retention of this element 
is inevitably somewhat lower in cow-milk feeding, 
and the great bulk of unavailable phosphorus passes 
off in the feces and urine. Furthermore, there is not 
sufficient phosphorus absorbed to combine with the 
supply of calcium in the tissues. Although, as we have 
seen, there is an enormous w-aste of calcium, still the 
amount absorbed is in excess of w r hat is required to 
bind the available phosphorus. The result is, that an 
additional quantity of calcium is excreted in the lower 
intestine, to increase still further the already large 
content of lime-soaps in the feces. 

We have noted the scanty supply of iron in cow t 's 
milk, quite insufficient to keep up the normal iron 
metabolism of the infant. This deficiency is made 
worse by the tendency of the iron to follow the calcium 
in its extremely wasteful economy. The wonder is 



86 COW'S MILK 

not that artificially fed children are almost invariably 
anemic, as shown by the hemoglobin test, but that 
they are not more so. 

The Ferments. — The ferments of cow's milk differ 
considerably from those found in human milk. Dias- 
tase seems to be entirely absent from the former, 
glycolytic ferment abundant, and catalytic ferment 
scanty (Friedjung and Hecht). These ferments are 
impaired or destroyed by heating the milk above 55° 
C. (131° F.), but not by chilling or even freezing. 
This circumstance has been made much of by the 
advocates of raw milk feeding; we have, however, 
seen in the preceding chapter, that the milk ferments 
play, at the most, a very subordinate part in the 
nutrition of breast-fed infants, and there is no evidence, 
that they are of any importance in feeding with cow's 
milk. It is being more and more generally admitted 
that the insistence on feeding with unheated milk, 
not long ago almost universal in this country, and 
largely based on the above premises, rests on a very 
unsubstantial foundation. It is at present exceedingly 
doubtful if the ferments of cow's milk have any 
influence on the food value of that fluid. 

MILK BACTERIA. 

Bactericidal Properties. — Probably because of the con- 
tained ferments, fresh milk does exercise some restraint 
on the growth of contained bacteria. Coplans found 
that this quality persisted, in a diminishing degree, for 
twenty -four hours, if the milk was simply left standing 



MILK BACTERIA 87 

at the room temperature, ('hilling to the freezing- 
point impaired this faculty, so that baeteria began to 
grow freely after nine hours; exposure to a temperature 
of 38° C. (100° F.) started free growth in six hours. 
Evidently there were two factors at work, on the 
one hand, the inhibiting power of the ferments, on 
the other, the thermic conditions of bacterial devel- 
opment. Hunziker found that the bactericidal or, 
better, inhibitory power, was most pronounced at 
21° C. (70° F.). We shall recognize the full impor- 
tance of these observations presently when we 
come to the question of the milk-supply. Other- 
wise this matter must be admitted as of minor 
importance, especially as the inhibitory action of 
fresh milk on bacteria is limited both in degree and 
duration. 

Milk Bacteria. — Whereas breast milk is ingested 
in an almost germ-free condition, this is impossible 
with regard to cow's milk under the most favorable 
circumstances. Milk forms one of the best imaginable 
culture media for countless harmless as well as patho- 
genic microorganisms, as is evident from its composi- 
tion, comprising, as it does, all the food elements. 
When we have in addition a temperature near blood- 
heat, as happens very often in the summer months, 
conditions are perfect for the growth of many of the 
most virulent germs. The elaborate investigations 
of Park and Holt differentiated no less than 239 species 
of saprophytic bacteria growing in milk; they found 
that ordinary store milk, sold from the can, might 
contain more than 20,000,000 bacteria to the cubic 



88 COW'S MILK 

centimeter; bottled milk, though far cleaner, not 
rarely contained 500,000 germs; whereas by observing 
reasonable precautions, milk containing less than 
10,000 was easily procurable. They found that it 
was quite feasible to furnish a nearly germ-free milk 
by adopting proper care in milking, and adequate 
provisions for keeping and transportation, and decided 
that milk containing above 1,000,000 bacteria to the 
cubic centimeter was unfit for human consumption. 

Milk Infection. More serious than saprophytic bacteria, 
which merely decompose the milk and cause illness 
through the production of poisons and toxins, are 
the recognized germs of infectious diseases, which may 
enter the milk through the most varied sources of 
contamination and find it a particularly effective 
culture medium. The literature on milk-borne 
epidemics of disease has recently grown to large pro- 
portions; we may here note the salient facts. 

For momentous and striking consequences, milk- 
borne typhoid fever heads the list. This source of 
infection caused hundreds of fatalities, in the city 
of New York alone in 1912 and 1913, though ordinary 
precautions had been taken and the infected supply 
was speedily cut off. In many of our cities, contami- 
nated milk has become the main source of this disease, 
which the most stringent regulations cannot eliminate 
entirely, so long as raw milk is consumed. After 
weeding out all other sources of infection, there still 
remains the danger of contamination by typhoid 
carriers, which cannot be guarded against with absolute 
certainty, under the best of supervision. The only 



MILK INFECTION 89 

preventive, that is infallible, is sterilization or efficient 
pasteurization of the entire milk-supply, as closely 
as possible to the time when it is handed to the con- 
sumer. 

Second comes tuberculosis, the germs of which are 
easily conveyed from the tuberculous cow to the milk, 
even if no bacilli are directly excreted by the udder. 
In addition there is the less frequent, though by no 
means negligible risk, of infection with human tuber- 
culosis from one of the many persons who handle the 
milk. Even the latter source is not easily controlled; 
the former, that is ever present, and can be eliminated 
only through destruction of diseased cattle, is at present 
taxing our state authorities to the utmost, with hitherto 
very unsatisfactory results. The tuberculin test shows 
that a very large percentage of our cows suffers from 
tuberculosis, and that the ratio tends to increase, in 
spite of the elimination of infected animals; carried 
out thoroughly, it is almost ruinous to the dairying 
industry, and a heavy burden on the State, which must 
pay the farmer for the cows that are condemned. The 
question has often been raised, whether the danger 
is sufficient to warrant such drastic and costly measures, 
especially since the bovine and human strains of 
tubercle bacilli have been differentiated. Theobald 
Smith claims that the danger is trivial unless the 
cow's udder is infected; nearly all authorities agree 
that the bovine bacilli cannot cause the familiar type 
of pulmonary tuberculosis. This last proposition, 
however, by no means disposes of the matter, for the 
forms of tuberculosis, here in question, while not as 



90 COW'S MILK 

severe as those caused by the human bacillus, are 
nevertheless serious, especially in children, and some- 
times have a fatal issue. Kober reports no less than 
86 cases in which tuberculosis could be traced to milk; 
Raw claims great frequency for infection with the 
bovine type, and Bovaird shows that these forms of 
tuberculosis are much commoner in England than 
American experience would lead us to suspect. Park, 2 
in a careful investigation, shows that about 2 per cent, 
of the fatal cases of tuberculosis in New York City 
are caused by the bovine bacillus; this looks like a 
small ratio, but signifies about two hundred deaths 
per year, a number that is certainly not negligible. 

Thus the possibility of tuberculous infection by 
bovine bacilli, of course through the alimentary tract, 
must be accepted as a fact, which would be even more 
conspicuous if the mass of the population were not in 
the habit of boiling all milk. Behring's stand-point, 
that infection with tuberculosis usually takes place 
in infancy, and through the digestive tract, may be, 
in some respects, too sweeping; so far as infection by 
bovine bacilli is concerned, however, there is today 
little doubt as to the correctness of his views. 

Many acute infectious diseases of other kinds are 
conveyed by milk. Thus, Hemenway reports an 
unquestionable epidemic of milk-borne scarlet fever; 
Brush describes the spread of foot-and-mouth disease, 
from infected cattle through the milk. Similar reports 
have been furnished by other observers. Still more 
interesting is the subject of throat infection with 
streptococci, derived from infected cows. Reed and 



MILK INFECTION 91 

Ward were the first to call attention to the significance 
of streptococci in the milk, showing that they were 
derived from mastitis in the cow; then Winslow and 
others reported a severe epidemic of sore throat in 
Boston and vicinity, which was easily traced to infected 
milk. Davis 2 finally cleared up the bacteriology of this 
disease by identifying the streptococcus in the human 
and bovine subjects. 

Most important of all, for us, is the infection of milk 
with bacteria of the dysentery group; this matter is 
still somewhat obscure in respect to the precise occasion 
and mode of transmission; the only certainty is that 
in warm weather a growth of bacteria takes place in 
impure milk, the ingestion of which causes dysentery 
in infants. The essential links in the chain are a high 
temperature and humidity of the atmosphere, to favor 
the growth of these special bacteria, and an impure 
milk-supply, swarming with germs ready to assume 
a luxuriant growth. The best proof that bacteria are 
essential to this type of infection is afforded by the 
fact that the morbidity is reduced to an astonishing 
degree by feeding the infants on milk that is either 
poor in germs or has been more or less sterilized. As 
to the symptomatology, pathology, and treatment of 
infantile dysentery, it forms so important a division 
of our subject as to merit a chapter by itself later on. 
At this point it is desirable to give only a few general 
data. 

It is as definitely settled, as anything can be, that 
impure milk is the cause of most of the extraordinarily 
high mortality of early infancy. The recognition of 



92 COW'S MILK 

this fact is one of the greatest triumphs of modern 
preventive medicine; with the improvement of the 
milk-supply, the decline in the infant death rate has 
been simply enormous. For example I give the deaths 
of infants under one year of age in the Boroughs of 
Manhattan and Bronx (old New York) for July, August, 
and September, for 1891-3, 1901-3, and 1911-3, tak- 
ing three-year averages to eliminate the influence of 
especially warm or cool summers. At the first date 
the care of infants of the poorer classes was still in 
what we now would call a deplorable state; the next 
ten years witnessed an extensive campaign in the 
education of mothers, with some partial efforts in 
the direction of milk-stations; the following decade 
was signalized by a marked improvement in the purity 
of the commercial milk-supply, rigidly enforced by 
ordinance. The figures are as follows: 



Infant Death rate 

Average of population. Deaths, per 1000. 

1891-93 48,000 4170 87 

1901-03 60,000 3244 54 

1911-13 82,000 2564 31 



The decrease is not only relative but absolute; the 
estimated annual saving of lives in the third period 
is about 4500, a veritable army of infants. Ten years 
ago I 1 considered the second line of figures quite flat- 
tering; they were succeeded by a few years of only 
slight improvement, so that we seemed to have nearly 
reached the limit. There is no doubt that the fall of 
the death rate would have practically come to a halt, 
had not the city authorities actively taken up the 



MILK REGULATION 93 

question of pure milk. The number of deaths for 
the fourth quarter of the year, the healthiest season 
for infants, for 1911-3, was 1876, 23 per 1000 living; 
this may be regarded as the normal, though still some- 
what reducible death rate per quarter for infants 
under one year. It will be seen that the city of New 
York has succeeded in accomplishing the greater 
portion of this task. 

Milk Regulation. — The regulations laid down in Jan- 
uary, 1912, by the Board of Health of New York City 
have been considered a model for other communities, 
but have nevertheless been improved upon by the 
same authority. According to these rules the sale of 
milk is placed under the following restrictions: 

Grade A milk, for infants and children, includes: 
(1) milk certified to by the milk commissions of the 
county medical societies; (2) milk subjected to similar 
supervision by the Board of Health and bearing its 
guarantee; (3) inspected milk, raw, from tuberculin- 
tested cows, averaging less than 60,000 bacteria per 
cubic centimeter and coming from farms meeting a 
definite standard as to equipment and methods; (4) 
selected milk, pasteurized, from farms coming up to 
a slightly less exacting standard, the pasteurization 
to be conducted according to rules of the Department 
of Health and the milk to contain not over 50,000 
bacteria per cubic centimeter when delivered to the 
consumer, the bottles to be marked "pasteurized," 
the maximum of bacteria before pasteurization being 
200,000 and the milk being delivered within thirty 
hours. 



94 COW'S MILK 

Grade B milk, for adults, includes: (1) selected 
milk, raw, from cows certified to as healthy by a veteri- 
narian, from farms of a high standard as to method 
and equipment; (2) ordinary milk, pasteurized, deliv- 
ered within thirty-six hours after pasteurization. 

Grade C milk, for cooking and manufacturing pur- 
poses only; all ordinary raw milk. 

The insufficiency of the above regulations was 
demonstrated by the typhoid epidemic of September, 
1913. The rules were thereupon modified as follows: 

No Grade B or C milk may hereafter be sold raw; 
this limits raw milk to Grade A, Nos. 1, 2, and 3. 

Still more recent regulations provide for the obser- 
vance of precise temperatures and duration of the 
pasteurizing process, as follows : 

Not less than 155° F. for at least 6 minutes 

152° F. " 12 " 

148° F. " 18 " 

145° F. " 20 " 

140° F. " 30 " 

It is doubtful if the best raw milk is perfectly safe; 
Rosenow found streptococci and pneumococci in certi- 
fied milk. Moreover, Cronheim and Muller found the 
proteins and fats of raw milk less thoroughly digested, 
and the casein curds, described before, are a character- 
istic feature of raw milk feeding, so that the superior 
food value of raw milk is doubtful. The ferment 
question is, as we have seen, of uncertain or, at any 
rate, minor importance. The supposed benefits to 
be derived from feeding with uncooked milk, when 
balanced against the dangers, which cannot be warded 



MILK REGULATION 95 

off entirely, even with the most painstaking care, 
render its advantages problematical, even on theo- 
retical grounds. 

It seems strange that recent writers, such as Rietschel, 
Zahorsky, and Schereschewsky, still attribute the 
high infant mortality, in the summer months, chiefly 
to the heat itself. Even before the recent improve- 
ments in the milk-supply I 1 showed that mere heat 
was only a contributing factor, calling for special 
precautions in the care of infants, but rarely causing 
illness by itself. To charge our troubles to the heat 
alone would be to give the matter up in despair, for 
our hot and humid summers are a fixed quantity, with 
which we are absolutely compelled to reckon. Fortu- 
nately, experience has shown that the question of 
summer mortality is chiefly bacteriological, and bac- 
teriological control of the milk-supply is now saving 
4500 infants annually in two boroughs of the city 
of New York alone. Against so momentous a fact the 
ablest presentation of theory becomes untenable. 

To secure a relatively germ-free milk seems a simple 
matter until we cast our eyes over a list of the things 
that must be kept scrupulously, almost surgically, 
clean. These include the pastures, barns, cows, milk- 
men's clothes and hands, receptacles for the milk, 
and cans and bottles for distribution to the consumers. 
Milk keeps well at 70° F. (21° C.) for a few hours, but 
must be cooled at least to 50° F. (10° C), to stand 
prolonged transportation. Milk is brought to New- 
York City from farms often more than three hundred 
miles distant, and many of them outside the juris- 



96 COW'S MILK 

diction of the State of New York. Even if all precau- 
tions are taken a cow may have developed tuberculosis 
since her last tuberculin test, a milkman may be an 
unsuspected typhoid carrier, or there may be careless- 
ness somewhere in the frequent handling of the milk 
en route to the consumer. The last is specially apt 
to occur if the milk is brought to town in cans and 
bottled on arrival, a practice still kept up by some 
dairies of good standing, but none the less objectionable. 

STERILIZATION. 

Milk may be absolutely sterilized by boiling it 
for fifteen to twenty minutes, and rendered sterile, 
as to pathogenic germs, by boiling for three minutes. 
Whereas prolonged heating undoubtedly injures the 
milk, especially the nucleins and lecithin (Baginsky 3 ), 
the idea that brief boiling impairs milk, as an article 
of food, is absolutely unsupported by evidence, and 
may be dismissed ; we have seen that the milk ferments, 
which are undoubtedly impaired, are probably quite 
unnecessary to the digestibility of the milk. Brenne- 
mann 1 voices the general opinion when he claims that, 
at the worst, boiled milk may sometimes cause con- 
stipation; it is highly improbable that, more than 
raw cow's milk, it is a factor in causing rickets, the 
danger of scurvy, so widely apprehended, is not involved 
in ordinary, imperfect sterilization, and can, further- 
more, be guarded against by simple methods, to be 
detailed later. Such careful observers as Ladd 3 and 
Finkelstein 2 are convinced that sterilized milk is quite 



PASTEURIZATION 97 

as digestible as raw milk. Any good thing may, 
however, be overdone, and I have seen a number of 
babies, often, be it noted, in the families of physicians, 
in whom strictly surgical sterilization of the milk 
had produced scurvy. This sort of sterilization, still 
more superheating under pressure, seems to impair 
the milk seriously, and has unquestionably led to 
the development of the disease mentioned. I may 
here note that, in former times, when the milk was 
merely brought to the boiling-point for a very short 
time, scurvy in infants was rarer than when thorough 
sterilization was adopted. 

Beattie and Lewis suggest the sterilization of milk 
by means of high frequency currents. 

PASTEURIZATION. 

Most of the real and supposed impairment of milk 
involved in sterilization may be avoided by the process 
known as pasteurization, which consists in heating 
the milk repeatedly, or for a prolonged time, to a 
temperature considerably short of the boiling-point. 
Relay, or fractional pasteurization, gradually kills all 
the bacteria by destroying them, as they germinate 
from the spores that have survived the moderately 
high temperature, at which pasteurization is carried 
out. Prolonged heating kills all the pathogenic bacteria, 
but some saprophytic germs survive in small numbers, 
so that the milk will not keep indefinitely, as will the 
completely sterilized article. The latter method of 
pasteurization has gradually supplanted the former, 
7 



98 COW'S MILK 

which is practically fractional sterilization, since we 
have learned that absolute sterility of the milk is not 
necessary, and possibly not desirable. There has been 
considerable discussion as to the most suitable tempera- 
ture for pasteurization, and the length of time that 
it should be kept up. Rotch 1 advises against tem- 
peratures above 68° C. (164° F.) as tending to injure 
the milk, but de Jong claims that the tubercle bacillus 
is not killed by a lower temperature than 72° C. 
(172° F.). We know that the complementary bodies 
of the ferments are destroyed at 56° C. (133° F.), so 
that any idea of preserving the latter and destroying 
the bacteria at the same time is illusory. Schorer 
thinks that a temperature of 63° C. (145° F.) kept up 
for thirty minutes fulfils all necessary requirements. 
The reader will have noticed that the new regulations 
of the New York Department of Health go into this 
matter in great detail. Schorer is right in insisting 
on strict official supervision of pasteurizing plants 
that work at moderate temperatures, for, under these 
conditions, the duration of the process is an essential 
factor in its effective performance. It is now admitted 
by all that moderate pasteurization, carried out in 
this way, does not impair the food value of the milk 
in any particular; in my own opinion, which I follow 
in my practice, milk treated in this way, if originally 
of good quality, is preferable to the highest grade of 
certified raw milk if we wish to adhere to the motto of 
" Safety first." 

Tonney and Pillinger recommend an ingenious plan 
for keeping milk during long journeys. A vacuum 



PASTEURIZATION 99 

bottle is first heated and then filled with milk warmed 
to 65° C. (149° F.); from this temperature the decline 
in the vacuum bottle will only be very gradual. So 
long as the contained milk maintains a temperature 
above 46° C. (115° F.) no growth of germs will take 
place, but if it falls below that point the milk must 
be consumed at once or discarded. I need hardly 
mention that this procedure requires careful ther- 
mometry, and very cleanly manipulation, especially 
when the temperature is being tested; carried out 
properly it should be invaluable for mothers travelling 
with infants, as the local milk-supplies, especially at 
the railway stations, are rarely to be trusted, and 
usually of extremely bad quality. 

One flagrant abuse of pasteurization must not be 
overlooked, but fortunately we can guard against 
it, and the newer official regulations have not lost 
sight of it. It consists in the constant temptation 
to dairies and milk dealers to pasteurize decomposed 
and even filthy milk so as to make it pass muster as 
being poor in living germs. Milk that originally con- 
tained more than 40,000,000 bacteria to the cubic 
centimeter has been thus passed off on the public as 
a tolerably pure article. It stands to reason that 
such milk remains unsafe in spite of pasteurization; 
the bacterial poisons contained by such milk are not 
destroyed by pasteurization and the dead bacteria 
remain, so that this article of food is almost as dangerous 
as if it had been delivered in its original state. To 
try to rehabilitate decomposed milk by means of 
pasteurization is a dangerous species of fraud, which 



100 COW'S MILK 

cannot be punished too severely. It can be prevented 
only by official control of the pasteurizing plants, 
in which inspection is made of the milk that comes in 
as well as of that which is sent out. 

Owing probably to the destruction of the bacteri- 
cidal ferments, sterilized or pasteurized milk does not 
keep as well as raw milk. 

CONDENSED MILK. 

Commercial condensed milk is of two kinds: the 
first is simply concentrated, by evaporation in vacuo, 
to about one-fourth of its original bulk; by adding 
to it three equal volumes of water we restore the original 
proportions of the ingredients. Thus prepared it is 
similar to highly sterilized milk in its food qualities 
as well as in its tendency to cause scurvy, unless pre- 
cautions are taken. It has the serious disadvantage 
of not keeping well once the bottle has been opened, 
and should not be regarded as more than an emergency 
food. Its continued use, once quite extensive, is to 
be severely deprecated. 

The second kind of condensed milk, sold in cans, 
is preserved by adding nearly 40 per cent, of cane- 
sugar; diluting with three volumes of water we have 
a sugar content of over 11 per cent. In discussing 
the digestive disorders of infancy we shall see how 
totally unsuitable this mixture is for infant-feeding; 
the sugar is present in a ratio that is unquestionably 
dangerous and likely to cause sugar intoxication in a 
very short time. Twenty years ago, when many babies 
were fed on diluted canned condensed milk, typical 



FROZEN MILK JO] 

sugar intoxication was exceedingly common in New- 
York at all seasons, not only in summer; it is more 
than probable that the increasing use of fresh milk 
is the chief reason why true cholera infantum has 
become relatively rare. In my early dispensary days 
we were fairly swamped with such cases, the mortality 
among them being simply appalling. 

I may add that Jordan and Mott find that condensed 
milk, despite its mode of preparation, is not always 
sterile, so that one of its supposed advantages is, to 
a certain extent, illusory. 

DESICCATED MILK. 

Desiccation is merely condensation carried out to 
to the limit, and the objections to condensed milk 
apply here equally. Desiccated milk may be a con- 
venient article for tropical or arctic expeditions — 
danger of scurvy (!) — but should have no permanent 
place in the infant's dietary. It is therefore strange 
to see it highly recommended by a whole school of 
French pediatrists, headed by Avignaret, but pleasing 
to note that Variot 1 and his followers visit it with 
unqualified condemnation. For my part it seems that 
any extended discussion of this product would be a 
waste of valuable space. 

FROZEN MILK. 

BischofT asserts that frozen milk is not harmful, 
and regards freezing as a rather good way of preserving 
milk; fortunately, few authorities agree with him. 
Shelmerdine reports an epidemic of winter diarrhea 



102 COW'S MILK 

caused by feeding infants with milk that had been 
frozen and thawed out, and is by no means alone in 
his experience; he specially notes that freezing affects 
the coagulation of the casein, and it certainly breaks 
up the milk globules, and therefore affects the digestion 
of the fats. The objections to freezing do not apply 
to cooling to near the freezing-point; on the contrary, 
mere chilling, performed directly after milking, and 
kept up until delivery to the consumer is one of the 
best means of preserving milk, and is now insisted 
on bv the official authorities. 



PRESERVED MILK. 

Our verdict on preserved milk varies according to 
the preservative employed. Budde's peroxid process, 
previously described in connection with human milk, 
is apparently quite unobjectionable, but not effec- 
tive beyond twenty-four hours, when it must be 
repeated ; it also suffers from being expensive and some- 
what difficult to carry out, and is therefore not in 
general use. Unscrupulous dairymen and dealers 
prefer the use of ordinary antiseptics, formaldehyde 
being the favorite; added in the proportion of 0.01 
to 0.1 gram to the liter, it is not absolutely bactericidal, 
so that the proportion added is usually considerably 
larger. Formaldehyde disappears from the milk in 
from one to four days without leaving a trace; its 
chemical detection is therefore often impossible, but 
it is a safe rule to suspect abnormally germ-free milk 
of this method of sophistication (Rivas). The addition 



MILK STATIONS 103 

of sodium benzoate is also Illegal; though Grulee and 
Buhlig arc satisfied that even sick infants can take 
0.15 to 0.3 gram (2.5 to 5 grains) of this substance daily 
without harm, it is very probable that this antiseptic 
interferes with the action of the digestive ferments. 
The same is true of boric acid, which is employed less 
frequently. Sodium fluorid is effective in preserving 
milk only if added in injurious proportions (Mazzeo); 
Schwyzer has shown that even 1 milligram per kilo 
of weight is harmful. Of course it must be borne 
in mind that the chief objection to the addition of 
preservatives to the milk is the fact that their use 
covers up negligence in milking and handling, which 
are the very faults that it is especially important to 
avoid. 

MILK STATIONS. 

Until very recently Grade A milk was limited in 
supply, and high in price; it was therefore obtainable 
only by the well-to-do, and sometimes was insufficient 
even for them. The mass of the population had to 
depend on ordinary commercial milk, now classified 
as Grades B and C, at that time not distinguished by 
official tests, and therefore often of exceedingly poor 
quality. The lowest grades of milk, dipped from open 
cans in the dirtiest possible manner, were sold at a 
price so low as to be almost a guarantee of decomposi- 
tion or adulteration, yet found ready customers in 
the poorer quarters of our cities. The first thing to 
do was to supply the masses with a reasonably good 
grade of pasteurized milk; this plan, inaugurated in 



104 COW'S MILK 

Paris by Variot, with great success, in the establish- 
ment of the gouttes de lait and consultations des 
nonrissons, was introduced into New York by Koplik 5 
in 1889, and on a larger scale by Nathan Straus in 
1893. It consisted in the opening of so-called milk 
stations in the poorer parts of the city, where whole 
and modified milk were sold to the mothers at 
cost, and advice on the care of infants was imparted 
by a competent personnel. During the succeeding 
eighteen years there was a gradual extension of this 
kind of enterprise on the part of various private insti- 
tutions and organizations, the key-note being a chari- 
table motive primarily, and public education only in 
a secondary way. In 1911 the city authorities began 
to supplement these activities by establishing stations 
in districts not hitherto provided for, so that at present 
the city is very well covered. 

It is idle to question the enormous value of the milk 
stations; the tables of mortality, before and since 
1893, tell their own story; every city in which the 
milk station has been introduced reports a rapid and 
continuous decline in the infant death rate, to figures 
that twenty years ago would have been deemed chime- 
rical. With all their good qualities, however, the milk 
stations, at least as now conducted, harbor a number 
of serious defects. In the first place, while there is 
ample provision for babies who tolerate cow's milk, 
the means for handling difficult feeding cases are utterly 
inadequate. Secondly, the formulas for modifying 
milk are rigid and unadaptable, fairly good for the 
majority of infants, but making no concessions to 
the more delicate and especially the very young babies. 



MILK STATIONS L05 

Thirdly, the instruction given at the stations, whether 
for home modification of milk, or in general infant 
hygiene, is almost futile if given to ignorant mothers, 
who are more or less unacquainted with the English 
language; the distribution of literature to persons 
who cannot read is particularly absurd. Fourthly, 
old-fashioned feeding methods even now prevail; 
the two-hour feeding interval, for example, is still 
being inculcated at the New York milk stations. 
Fifthly, there is too little medical control, too much 
incorrect medical advice is permitted to be given by 
trained nurses, who are only too willing to grapple 
with difficult feeding problems which are entirely 
beyond their ken. Sixthly, last but not least, comes 
the pauperizing effect of these institutions. Under 
the new milk regulations it is possible to buy good 
pasteurized Grade A milk at a reasonable price from 
reliable dealers; there is no reason why the city 
authorities or charitable institutions should continue 
to give milk at cost indiscriminately to all persons 
who apply. It is pleasing to know that the authorities, 
in the city of New York, are seeking to avoid this 
evil (Baker), but the temptation to make a numerical 
record is always great. 

Haas objects to the term "milk stations" as tending 
to discourage breast-feeding, as well as to the milk- 
selling feature; he thinks that they should be called 
"baby stations," and that the milk should be bought 
outside; his arguments are surely worthy of careful 
consideration, and in close accord with my own experi- 
ence. In my service at the Mount Sinai Hospital 



106 COW'S MILK 

Dispensary most of the difficulties in feeding sick or 
delicate babies were removed at one sweep when the 
hospital board assigned a visiting nurse to the pediatric 
department of the dispensary, and very wisely detailed 
her from the social service staff of the hospital, so that 
the dispensary and the social service division could 
work together through one visiting agent. Home 
instruction in the modification of milk and the general 
care of the infant, carried out under hospital or dis- 
pensary supervision, is the true solution of the feeding 
problem among the poor; at the mentioned hospital 
the results have been so gratifying as amply to atone 
for the still postponed installation of a milk station, 
once strongly urged, but now no longer urgent, since 
the public milk-supply has become so well guarded by 
official vigilance. An essential part of this scheme is 
a visit by the nurse, at least once weekly; the baby 
is brought to the dispensary fortnightly, to be generally 
looked over, weighed, and have its feeding regulated 
for the following two weeks. In the case of sickly 
infants, and such as need special feeding, the appro- 
priate formulas can be drawn up by the attending 
physician, and the mother taught by the visiting 
nurse, to prepare the milk accordingly; in these 
cases, visits and calls should be more frequent, a varia- 
tion easily carried out. The question of supplying 
the food gratis, or at cost, can easily be studied out 
in the individual case, the very individualization being 
a guarantee against wholesale pauperizing. 

This plan does not interfere with the activities of 
the Department of Health, in inspecting homes and 



WHOLE MILK FEEDING 107 

ferreting out negleeted and siek infants, which are 
then referred to the nearest dispensary. The best 
results can undoubtedly be achieved by the cooperation 
of both agencies. 

WHOLE MILK FEEDING. 

After our prolonged discussion of the digestibility 
of cow's milk, and the means of obtaining it of good 
quality, we pass on to observe the results of feeding- 
infants on unmodified or whole milk. This is unques- 
tionably a very good food, after the age of nine months, 
and forms the staple of the infant's dietary during 
most of the second year; by that time the baby's 
digestion usually becomes equal to the absorption of 
the fats that are so troublesome in early infancy, and 
the gain in weight is likely to be satisfactory, or even 
above the average. In early infancy, however, as may 
be surmised from what has gone before, pure cow's 
milk is a rather dangerous food. It is true that some 
infants, especially after the first few months, do fairly 
well on it, and I could mention a series of authorities 
who do not hesitate to give it after the age of three 
months. The general experience, however, is decidedly 
to the contrary; the successes, just referred to, dwindle 
into nothingness beside the vast volume of disastrous 
results to young babies, from whole milk-feeding; 
in fact it seems strange that any pediatrist should 
still try systematically to feed infants, under the age 
of nine months, with undiluted cow's milk. The dis- 
cussions that have filled this chapter strictly refer 



108 COW'S MILK 

only to the food for older infants, and the raw material 
for the young baby's diet; the latter will be elabo- 
rated in the following chapters, where the modification 
of cow's milk is considered. 



MILK IDIOSYNCRASY. 

Some infants simply will not tolerate cow's milk, 
no matter how carefully modified; they may truly 
be said to manifest an idiosyncrasy. Many authors 
have assumed that this intolerance represents an 
anaphylactic reaction to the proteins of cow's milk; 
to mention but a few, I cite Schlossmann, 1 Moro, 1 
and Kleinschmidt in support of this view. Their 
stand-point is as follows: The cow-milk proteins are 
probably not identical with those of human milk, as 
is shown by the different relation of the casein to the 
whey proteins and the phosphorus, and still more 
emphatically by the successful sensitization of animals, 
by Bordet and Wassermann, through the injection 
of the milk of different species. Kleinschmidt suc- 
ceeded in sensitizing guinea-pigs to cow's milk by 
way of the intestinal tract. Freund 4 found that 
fat-indigestion played no part in true idiosyncrasy, 
that the condition itself was exceedingly rare, but 
that his one case also manifested anaphylaxis to 
tuberculin, whenever cow's milk was given; he sus- 
pected the whey proteins as the cause of the reaction, 
in this point agreeing with Kleinschmidt. 

The majority of pediatrists, however, do not accept 



MILK IDIOSYNCRASY 109 

the anaphylactic theory of intolerance to cow's milk. 
Finkclstein 3 is skeptical, Langstein 2 and Meyer 3 are 
convinced that the difference in the proteins plays 
no role whatever. Lust 2 lays down the following 
requirements for those who would prove anaphylaxis: 
(1) they must find a reaction to cow-serum in the blood 
of the affected child; (2) they must prove the passive 
transmissibility of anaphylactic antibodies; (3) they 
must show the development of anti-anaphylaxis after 
the attack. These requirements have hitherto not 
been met; we have not even any proof that the casein 
and lactalbumin of cow's milk differ from those of 
human milk, though the possibility and even probability 
of this must be considered. The present situation is 
one of doubt, but the evidence seems to point to the 
occurrence, in rare cases, of true anaphylaxis, while, 
on the other hand, many cases of supposed anaphylaxis 
must be explained otherwise. It is absolutely certain 
that many infants encounter difficulties, in digesting 
cow's milk, that do not require the calling in of anaphy- 
laxis, to explain what can be accounted for on much 
more simple grounds. Anaphylaxis is strictly a protein 
reaction, and it is now pretty well settled, that the 
proteins rarely give trouble, even when the other 
elements of the milk are badly borne; there is no doubt, 
that former prejudices against the cow-milk proteins 
have been potent in influencing observers, and that 
the anaphylactic theory of milk intolerance is losing 
ground, in all probability being applicable to only very 
few cases. 



110 COW'S MILK 

MILK OF OTHER ANIMALS. 

The difficulties attending artificial feeding with 
cow's milk have led to a search for more digestible 
foods and to attempts with the milk of other animals. 
Goat's milk is in widespread use in some parts of 
Europe, and is extensively given to infants; examina- 
tion and analysis have shown it to be very similar 
to cow's milk, as is indeed to be expected, on zoological 
grounds. McLean, however, has shown that goat's 
milk is relatively rich in iron, a consideration that 
might be of advantage in treating and preventing 
infantile anemia. As goats are relatively rare animals 
in this country, and there seems to be little inducement 
to raise them here, the question of substituting their 
milk for that of cows can hardly come up in a practical 
way. The milk of mares and asses has been recom- 
mended by European authors; both are relatively 
poor in fat, containing about one-half the percentage 
present in cow's milk. As the young of these animals 
are also born in a comparatively mature state of 
development, it is to be feared that these species of 
milk are also unsuited to the digestive apparatus of 
young babies; at any rate, it has not yet been proved 
that they have any special value for our purpose. 
In view of the above facts, the idea of replacing cow's 
milk with that of other animals has hardly passed 
beyond the stage of suggestion; it is more than doubtful 
if any advance in infant feeding can be effected along 
this line. 



CHAPTER IV. 
MILK MODIFICATION. 

We have seen that most infants, under the age of 
nine months, are more or less incapable of digesting 
pure cow's milk. For many generations the apprecia- 
tion of this fact has led to endeavors at modifying 
this article of food so that the infant might tolerate 
it and thrive on it. 

Milk may be modified in three ways: (1) by simple 
dilution; (2) by varying the proportions of its con- 
stituents; (3) by adding foreign substances. Many 
well-known methods combine two or all of these. 

SIMPLE DILUTION. 

Simple dilution may be handled very briefly. It 
is clearly illogical to reduce all the ingredients of 
the infant's food merely because one of them is 
giving trouble; to do so is simply to substitute 
starvation for indigestion, undoubtedly a fairly good 
measure for a few days, but sure to be harmful 
when long continued. Even undiluted cow's milk, 
if we allow for the imperfect utilization of the fats, 
is somewhat deficient in caloric value; by merely 
adding water we diminish the food value still further; 



112 MILK MODIFICATION 

we may increase the digestibility, but only as any 
starvation diet rests the gastro-intestinal tract. For 
continued use, this form of modification must unhesi- 
tatingly be rejected. 

We may therefore pass on at once to the second type 
of modification, in which the proportions of the ingre- 
dients of the milk are altered. 



REMOVAL OF CASEIN. 

If we add 5 grams (1 teaspoonful) of rennet to 
1 quart (liter) of milk, which must be slightly acid, 
keep the mixture at a temperature of about 100° 
F. (38° C.) until it separates into a liquid and a 
solid portion, and then strain it through cheese-cloth, 
we have practically all the casein, as paracasein, 
left on the cloth, the filtrate being the fluid known as 
whey. It is advisable to break up the curd before 
straining, so as to obtain, as nearly as possible, a pre- 
cipitate of paracasein alone; nevertheless, about two- 
thirds of the milk fats become entangled in the curd, 
so that the whey, besides the whey proteins, contains 
only about one-third of the fats, but nearly all the 
milk-sugar and salts. As the filtered whey still con- 
tains the rennet it must be heated to at least 140° F. 
(60° C.) for thirty minutes to destroy that ferment. 

The average composition of whey is as follows : 



Proteins 0.8 per cent. 

Fats .1.0 

Milk-sugar 4.5 " 

Salts 0.7 

Water 93.0 



REMOVAL OF CASEIN 113 

As usually made, whey still contains about 0.2 per cent, 
of casein, because of imperfect precipitation (Grulee) . 

Whey is a thin, watery fluid, looking very much 
like skimmed milk; its caloric value is only about 
300 per liter, 9 per ounce, barely one-half that of 
whole milk; it is therefore adapted only to temporary 
feeding. While its low fat content is of great value 
in cases of fat-dyspepsia, its employment nevertheless 
rests on the old fallacy of the harmfulness of casein, 
and is unsound for that reason. It is not surprising 
that the enthusiasm for whey-feeding, without any 
addition, in digestive disorders, so prevalent a few 
years ago, is now on the wane. For an especially 
high recommendation of this fluid, see Southworth, 2 
who does not by any means stand alone; on the other 
hand, at practically the same date, we find Westcott 
crediting whey with the causation of colic, and far 
from enthusiastic. Since then Leopold and Muller 
have shown that it rather tends to promote sugar 
intoxication if a serious digestive disturbance is 
already present, the very condition for which it is 
recommended. LaddY suggestion to employ whey 
as a milk diluent instead of water may occasionally 
be of use, as it avoids the excessive starvation, and 
more particularly the very low sugar percentage, 
obtained by adding water alone. A mixture of half 
milk and half whey gives the following : 

Proteins 2.1 per cent. 

Fats 2.5 

Milk-sugar 4.5 

Salts 0.7 

Water 90.2 



114 MILK MODIFICATION 

Calories: 490 per liter, 15 per ounce; an important 
objection is the high ratio of salts, which is an inherent 
fault of whey-feeding, and probably responsible, in 
many cases, for the disturbances attributed to the 
sugar. This subject will be discussed in full in a later 
chapter. 

REMOVAL OF FAT. 

If we allow milk to stand in a cool place for eight 
hours, and remove the upper, yellowish layer with a 
dipper, we have, as a residue, the fluid called skim 
milk, the composition of which is as follows: 

Proteins 3.5 per cent. 

Fats 0.5 

Milk-sugar 4.5 " 

Salts 0.7 

Water 90.8 

Its caloric value is about 360 per liter, 11 per ounce; 
its food value is therefore slightly greater than that 
of whey, the ample supply of proteins more than making 
up for the reduction in fats, and rendering it, from the 
modern point of view, decidedly superior as a temporary 
food, in cases of fat-indigestion. Of course, its continued 
use is sure to entail a loss of weight. Its sugar and 
salt percentages, especially the latter, are rather high 
for employment in infants presenting symptoms of 
intoxication, but for simple fat-dyspepsia, skim milk 
is among the best temporary foods available. 

Removal of Casein and Fat. — This is accomplished 
by making whey of skim milk instead of whole milk; 
such whey differs from the ordinary kind, in containing 



REMOVAL OF FAT 115 

mere traces of fat, not over 0.2 per cent., with a further 
reduction of caloric value to about 230 per liter, or 7 
per ounce. The administration of this fluid is prac- 
tically equivalent to giving salted sugar-water, as it 
involves both fat and protein starvation. The danger 
of inducing intoxication is, if anything, increased by 
such a diet, and as a routine feeding, for infants suffering 
from digestive disorders, it is likely to do more harm 
than good. 

Buttermilk. — Buttermilk may be classed with the 
fat-free types of milk, but differs in containing free 
lactic acid. It is prepared as follows: To wmole milk 
is added a pure culture of some form of lactic acid 
bacillus as a " starter;" this germ gradually decom- 
poses some of the milk-sugar into lactic acid; the 
free acid, in turn, breaks up the milk globules, forming 
fatty coagula. When these coagula are fully formed, 
whereof the dairyman judges by experience, the milk 
is actively churned, and the coagula are thereby 
agglomerated into the fatty mass called butter, which 
is strained off, leaving the acid residue known as 
buttermilk. 

Freshly made buttermilk is a slightly sour, thin, 
liquid, containing the following ingredients: 

Proteins 3.3 per cent. 

Fats 0.5 

Milk-sugar 4.0 

Salts 0.7 jj 

Lactic acid 0.8 

Water 90.5 

The caloric value is about 340 per liter, 10 per ounce. 
Buttermilk must be immediately pasteurized to kill 



116 MILK MODIFICATION 

the lactic acid bacilli, otherwise there will be formed 
an excess of acid, with a corresponding loss of milk- 
sugar. Delay or neglect in this particular is responsible 
for the frequently excessive acidity of commercial 
buttermilk, which, moreover, has a marked tendency 
to undergo putrid decomposition, so as to become 
unfit for human consumption. 

It will be seen that buttermilk differs from skim milk 
chiefly in a slight loss of lactose, and the presence of 
lactic acid. Menschikoff does not hesitate to declare 
it practically equivalent to skim milk. It is, therefore, 
a very insufficient food for continued use unless other 
food substances are added to it. Buttermilk should 
by no means be confounded with acidified milk, which 
it resembles only in containing free lactic acid; this 
confusion pervades the whole literature on the subject, 
renders many articles on the question quite worthless, 
and has misled the consuming public to a degree that 
is almost inconceivable. This confusion is all the 
more unfortunate in that there is every reason to 
believe that the free lactic acid is a very unimportant 
constituent in buttermilk, as suggested by Menschikoff, 
just quoted. On this point we may once more refer 
to the investigations of Bahrdt and Bamberg, mentioned 
on page 22, showing that this small ratio of lactic 
acid is practically without influence on digestion or 
intestinal peristalsis. 

Buttermilk, as a regular food, is never given alone, 
but always has carbohydrates added to it; we must 
allow for this in analyzing the reports on this prepara- 
tion, which otherwise are incomprehensible. These 



REMOVAL OF FAT 117 

mixtures have been used for generations in Holland, 
but their modern general application dates from the 
communications of de Jager and Teixeira de Mattos, 
awakening the interest of the Germans, who at once 
subjected them to a series of thorough clinical experi- 
ments, giving them the name of buttermilk-soup. 
The different authors vary slightly as to the ingre- 
dients: Koeppe 2 adds 60 grams of cane-sugar and 15 
grams of wheat-flour to the liter of buttermilk, stirs 
thoroughly, and boils three times; Cardamitis adds 70 
grams of sugar and 13 grams of rice-flour; among 
Americans, Holt 1 is more cautious in adding carbohy- 
drates, limiting the addition to 30 grams of barley-meal 
and 8 grams of cane-sugar. These various additions 
all add a caloric value ranging from 150 to 300 per 
liter, or 4.5 to 9 per ounce, increasing its food value 
to near the normal requirement, but involving the 
greatest possible risks. Tugendreich, for instance, 
had unpleasant experiences with what he called 
buttermilk-fever; Finkelstein 6 has not the least hesi- 
tation in identifying buttermilk-fever with sugar 
intoxication, and his view becomes justified, when 
we look at the carbohydrate percentages, 11 to 12 
in the mixtures of Koeppe 2 and Cardamitis, and about 
the same in other cases; Holt's more rational carbo- 
hydrate percentage of about 8 is just so much less 
likely to lead to intoxication. 

Turning to reports that are built on erroneous 
premises, I merely mention Glaessner's as an instance. 
He thinks the high fat ratio harmful, some of his 
preparations containing over 2.5 per cent. Of course, 



118 MILK MODIFICATION 

he bad not used buttermilk at all, but must have been 
imposed upon by a manufacturer; the case only 
goes to show how uncritical are many of the reports 
of experiences with this substance. As it happens, 
the low fat percentage constitutes, in the long run, a 
standing objection to the continued use of buttermilk- 
soup, even if its caloric value has been made nearly 
normal. 

Overrated as buttermilk has been, we must not 
ignore its useful qualities. Rommel sees advantages 
in the fine division of the casein, the tendency of the 
lactic acid to prevent decomposition — a very doubtful 
point, this — and the circumstance that less calcium is 
lost by being bound to fatty acids. He admits that it 
is too low in fat for continued feeding, and, as usually 
given, too high in carbohydrates, and that the salt 
metabolism is not more advantageous than in feeding 
with ordinary milk, save for the calcium. 

REMOVAL OF WHEY. 

Albumin Milk. — Separation of the whey is effected 
by first warming a liter (quart) of milk to 100° F. 
(38° C), adding one-half ounce (15 grams) of essence 
of pepsin, stirring gently, and keeping the mixture 
at the above temperature for half an hour. This 
gives us the familiar junket, or curds and whey. We 
then strain off the whey through linen for half an hour, 
without squeezing the curd; the whey is rejected. 
Next we rub the curd through a fine sieve with a wooden 
spoon, using a pint of water in doing so; this gives us 



REMOVAL OF WHEY 



119 



an emulsion of the curd of a quart of milk, in a pint 
of water. To this is added a pint of buttermilk; the 
result is a quart of what Finkelstein and Meyer eall 
Eiweissmilch, i. e., albumin-milk. 

We can understand the composition of albumin- 
milk best, by noting the source of its constituents. 
It is presumed that the original milk contains 3.5 
per cent, of proteins, and 4.0 per cent, of fats. 



Casein 

Whey proteins 

Fats . . 

Milk-sugar 

Salts . . 

Lactic acid 

Water 



?rom quart 


From pint 


In quart of 


of 


of 


albumin- 


whole milk, 


buttermilk, 


milk, 


grams. 


grams. 


grams. 


24.0 


12.0 


36 




4.0 


4 


26.0 


2.0 


28 




20.0 


20 


0.5 


3.5 


4 




4.0 


4 
904 



If w T e start with milk containing only 3 per cent, 
of proteins and 3.5 of fat, the casein and fat will be each 
about 0.5 per cent. low r er in the resulting albumin- 
milk, agreeing closely with the published analyses 
of Pelka and others. The caloric value of albumin- 
milk is about 490 per liter, 15 per ounce; according 
to Pelka's analysis about 430 per liter, 13 per ounce, 
neither so very much below T a sick infant's requirement, 
and therefore not involving the disadvantages of semi- 
starvation, involved in the products before mentioned. 

We must remember that the casein curd always 
includes in its meshes about two-thirds of the fats. 
Albumin-milk, therefore, is characterized by a very 
large casein content, rather exceeding that of w 7 hole 
milk, a lowering of the fats by about one-third, and 



120 MILK MODIFICATION 

a reduction of the whey protein, sugar and salts, by 
about one-half. According to Finkelstein and Meyer, 1 
the whey elimination is the essential point, some 
of the resulting food-deficiency being made iip with 
the additional casein. 

Pelka's very complete analysis gives the salts in 
detail: of a total of 0.44 per cent, he finds 0.13 phos- 
phoric acid, 0.07 chlorin, 0.09 lime, 0.09 potash, 0.06 soda. 

The precise technique of preparing albumin-milk is 
of great importance; the method just described must 
be carried out with the utmost accuracy. Properly 
made it is an opaque fluid, filled with fine flakes, which 
should settle to the bottom very gradually on standing; 
there should be present no casein lumps nor any separa- 
tion into layers, except as mentioned. The taste is 
peculiar, a little but not quite like buttermilk, and 
some infants do not fancy it at first. Its relatively 
high caloric value usually keeps the baby's weight 
from declining; sometimes there is even a slight gain, 
especially in the earlier period of administration. 

Wilcox and Hill recommend albumin-milk made of 
skim milk. This variation of course reduces the fats 
nearly to zero, and renders the product very insuffi- 
cient as a food. It remains, nevertheless, rather superior 
to ordinary buttermilk, because of its high protein 
content, and is therefore useful, if we wish to compen- 
sate for low ratios of both fats and carbohydrates, 
by running up the proteins, a plan that is subject to 
extremely narrow limitations, as we have already seen. 
Their suggestion may, however, be most profitably 
utilized, if we subject the milk to partial skimming. 



REMOVAL OF WHEY 121 

By removing the upper two ounces from milk that 
has been standing eight hours, we take away about 
40 per cent, of the fats; by removing four ounces, 
we take away about 60 per cent.; in this fashion wc 
can adjust the fat percentage very much as we please 
to suit the individual case. 

Most of the milk modifications^ so far discussed, 
are suitable only for sick babies, being too low in food 
value for normal infants. In the case of albumin-milk, 
however, it is possible to continue for some time 
after convalescence by gradually adding 4 per cent, 
of carbohydrates, preferably malt; we can thereby 
increase the caloric value to 600 or 640 per liter, on 
which a steady gain in weight regularly sets in. The 
possibilities of albumin-milk, as a regular article of 
diet, have hitherto hardly been realized; I would 
therefore like to call attention to papers by Brady 2 
and Benfey, the latter of whom gave it to a large number 
of newborn infants, with uniformly satisfactory results. 
I have given it for as long as six weeks, discontinuing 
it chiefly because the patient no longer required a 
food that was so troublesome to prepare. 

The last feature has been the great obstacle to the 
general employment of albumin-milk; nurses have 
to be specially trained to prepare it properly, so that 
the casein does not gather into lumps that cannot 
pass through the perforation of the nipple. Engel 2 
tries to obviate this defect by very careful dosage of 
the coagulating ferments, but practically he only sub- 
stitutes another technical difficulty for the one men- 
tioned. Hoobler 3 has tried the addition of powdered 



122 MILK MODIFICATION 

commercial casein, of the purest obtainable quality, 
to buttermilk, thus obtaining a fat-free albumin-milk; 
this plan seems to have some merit, so' far as it goes, 
but the fat-free variety is not usually the kind desired, 
so that the problem is only partly solved at best. 

The details of albumin-milk feeding, especially as 
they apply to sick infants, are best reserved for later 
consideration, when we come to discuss the treatment 
of intestinal diseases. 

Albumin-cream-milk. — Quite recently, Feer 3 has sug- 
gested a substitute for albumin-milk, very similar 
in composition, with the advantage of being very 
easily prepared; he calls his product albumin-cream- 
milk. This mixture is compounded of 500 grams of 
whole milk, 50 grams of 20 per cent, cream, 10 to 15 
grams of Nahrzucker (dextrin-maltose), 15 grams 
of plasmon (sodium-casein), and 600 grams of water. 
The food ingredients of this preparation figure out 
about as follows: 

Casein 2.6 per cent. 

Whey proteins 0.4 " 

Fats 2.6 

Carbohydrates \ . . . 3.5 " 

Salts 0.4 

Water 90.5 

Albumin-cream-milk contains a little less casein 
and a little more sugar than Finkelstein's albumin- 
milk. Its caloric value is about 500 calories per liter; 
Feer says 600, but I cannot see how he obtains this 
figure. This preparation cannot only be employed 
like albumin-milk for sick babies, but, like it, seems 
of some value as a regular article of infant diet. Feer, 



ADDITION OF FAT 123 

however, saw scurvy set in after three months' use 
in one case and severe rickets in a few others, so that 
this modification must also be employed cautiously 
and excessive sterilization avoided. 



ADDITION OF FAT. 

Top-milk. — The simplest, and therefore the uni- 
versal method of increasing the fat content of the 
infant's food, is to use cream or top-milk in preparing 
the desired mixture instead of whole milk. Cream 
obtained by the centrifugal process is so variable in 
its fat percentage that it can only be used in a labora- 
tory, where the proportion of fat can be checked off 
by the Babcock test; for general use the employment 
of top-milk is more accurate and trustworthy. In 
making use of top-milk it is necessary to know before- 
hand the percentage of fat in the whole milk; we have 
seen that this also varies greatly. We can, however, 
limit this variability, by confining ourselves strictly 
to milk from the commoner grades of cattle; we may 
then be sure that the percentage of fat is not above 4, 
and possibly not above 3.5. 

Taking milk containing 4 per cent, of fat as our 
standard, and assuming that it has stood in a cool 
place for six or eight hours, the fat ratios of the different 
levels are approximately as follows: 



Upper two ounces 

Next 
Next 
Next 
Next 

Next 



24 per cent, fat \ upper 4 ounces 2 0.0 per cent, fat 



second 4 " 8.0 
third 4 " 1.5 



124 MILK MODIFICATION 

Below this level the ratio of fat is about 0.5 per cent, 
down to the bottom of the bottle: this is therefore 
the proportion of fat in skim milk. 

From the above data we can deduce the following 
figures : 

Upper 4 ounces 20.0 per cent, fat 

6 " 17.0 

8 " 14.0 

10 " 12.0 

12 " 10.0 

16 " 7.5 

20 " 6.0 

We must not forget that milk containing only 3.5 
per cent, of fat will give results one-eighth lower and 
3 per cent, milk one-fourth lower. 

Let us consider the various points that make up what 
we may call the theory of top-milk feeding. In the 
first place there is the endeavor to provide ample 
caloric value; in this respect the method must be 
regarded as successful. Secondly, there is the idea that 
casein is not very digestible, and that it is advantageous 
to give it in a rather low ratio, making up the shortage 
with fats; this principle we have seen to be fallacious. 
Thirdly, comes the attempt to present casein and fat 
in the proportions that occur in human milk; to effect 
this the milk is diluted until the casein is brought 
down to the desired percentage and top-milk added 
to raise the ratio of fats, as well as sugar to bring the 
carbohydrate proportion to normal. A priori, this 
should give us a faithful reproduction of human milk; 
in practice, we have learned that this is not at all the 
case; the facts and experience have run counter to the 



ADDITION OF FAT 125 

theory. Regardless of the mathematieal niceties of this 
method, a very large proportion of infants do badly on 
top-milk mixtures. 

The numerous disadvantages of top-milk feeding 
arise from two causes: (1) the inherent defects, in 
addition to those just mentioned, and (2) the tech- 
nical errors committed in carrying it out. Among the 
former group, I may mention that the milk-bacteria 
tend to rise to the top of the bottle, and are nearly 
twice as numerous in the uppermost two ounces as 
lower down (Torrey and Rahe); this necessitates the 
use of exceptionally pure milk, to begin with. Next 
comes the impossibility, for many young infants, of 
digesting the cow-milk fats, if given in the proportion 
of the fats in human milk. No doubt, some babies, 
especially in the second half-year, tolerate overloading 
with cow-milk fats, and some even manage to gain 
rapidly on an excess of this food; on the other hand, 
nothing is more clearly established than that most of 
the failures in infant feeding are due to the giving of 
high fat percentages, as will be shown more fully 
later on. 

Turning to technical errors, we come to the inac- 
curacy of top-milk feeding, a fatal defect in a method 
that rests on a mathematical foundation. We have 
noted the variability of the fat ratio in cow's milk, 
the exceedingly high proportions furnished by certain 
breeds of cattle, and the impossibility of controlling 
this factor unless we have an extensive laboratory 
equipment at our command. Extraordinary care 
must be exercised in top-milk feeding in this regard; 



126 MILK MODIFICATION 

the mere fact that we run so close to the limit of safety 
in giving the least digestible milk ingredient causes 
the danger of overstepping the line to be ever present. 

The second technical error, not absolutely inherent 
in the method, but committed by all its advocates, 
is the short feeding interval, which is given in all the 
tables. I shall endeavor to show, later on, how this 
defect may be eliminated. It is certainly responsible 
for some of the failures chargeable to top-milk; many 
an infant might have tolerated it fairly well, if its 
stomach and intestine had not been persistently over- 
loaded by too frequent feeding. 

I pass over the circumstance, that the top-milk 
method has never paid any attention to the sugar 
and salt metabolism; these omissions were excusable, 
at the time that this type, of feeding was proposed, as 
the possible disturbances caused by these ingredients 
were imperfectly understood; today we have no right 
to continue to ignore these factors which so often are 
of vital importance. 

Let us now pass on to a few of the feeding methods, 
based on the theory of top-milk. 

1. Biederfs Mixture. — This method is the parent 
of those that follow. Biedert took 125 grams (4 
ounces) of 10 per cent, cream (the upper third of the 
bottle) and added thereto 375 grams (12 ounces) of 
water and 18 grams (0.6 ounce) of milk-sugar. As 
the infant grew older he added successively 62, 125, 
250, and 375 grams (2, 4, 8, and 12 ounces) of milk; 
this made a total of five formulas, giving the following 
percentages of food-ingredients: 



Formula. 

Proteins . 
Fats . . 
Milk-sugar 

Salts . 
Calorics 



ADDITION OF FAT 12' 



per cent. 



320.0 350.0 390.0 440.0 480.0 per liter. 



I. 


II. 


III. 


IV. 


V. 


0.9 


1.2 


1.4 


1.7 


2.0 


1.0 


1.3 


1.0 


2.0 


2.3 


4.8 


4.8 


4.8 


4.8 


4.8 


0.2 


0.25 


0.3 


0.38 


0.45 



The actual number of calories ingested, Biedert's 
figures giving the daily ration, is 160 for the first 
formula and 420 for the fifth. These are the amounts 
we would now give to newborn and two-months babies 
respectively; Biedert gave them at much later ages. 
Perhaps this fact accounted for some of his successes, 
for he certainly did not run the risk of overfeeding 
with fats and carbohydrates, while the protein ratio 
was approximately normal. 

2. Meigs' Mixture. — Meigs proceeded in somewhat 
different fashion. He drew off the upper half of the 
bottle (7.5 per cent, fat), added to three ounces of 
this top-milk, three ounces of a 15 per cent, solution 
of milk-sugar and two ounces of lime water. This 
mixture he gave throughout infancy, merely increasing 
the quantity as the child grew older. 

Made with ordinary milk (4 per cent, fat), the 
composition of Meigs' mixture is as follows: 



Proteins 1.3 per cent. 

Fats 2.8 

Milk-sugar 7.3 

Salts 0.3 

Water 88.3 



Meigs preferred to make his mixture with rich milk, 
endeavoring to obtain the excessive fat percentage 
of 4.7, quite feasible, if Jersey milk of the best quality 



128 MILK MODIFICATION 

is used, but altogether objectionable, as we have seen. 
The caloric value of the analysis, given above, is 
about 550 per liter, rather high for earliest infancy, 
and too low afterward. Meigs' employment of rich 
milk might raise the number of calories to 770, which 
is certainly a little too high. His method involves 
other errors; the amount of proteins is much too low, 
that of carbohydrates rather high for the first month or 
two. It is easy to see that there must have been many 
failures with his modification. 

3. Rotch's Mixtures. — Rotch's method is usually 
regarded as synonymous with the percentage method, 
and is often called, par excellence, the American method; 
we have, however, observed that the percentage idea 
originated with Biedert; the national appellation is 
rather derogatory, for its narrow limitation to this 
side of the Atlantic is by no means flattering, foreign 
observers having noted some of its defects from the 
first. Credit must, however, be given Rotch for the 
recognition of two facts: first, that different children 
require different food concentrations, and that no 
single formula or even five formulas, will satisfy these 
requirements; secondly, he saw more clearly than 
Biedert, that the tolerance of cow's milk varied enor- 
mously according to age. In response to these demands, 
he drew up tables following Escherich 4 in seeking to 
imitate, within a fraction of 1 per cent., the poorer, 
medium, and richer types of human milk, adapting 
these variations to the different ages of infants, but 
reserving, which is important to remember, the right 
to deviate from this routine in the individual case, 



ADDITION OF FAT 



129 



when the condition of the infant's digestion and metab- 
olism seemed to call for it. 

The result is necessarily intensely artificial, and the 
artificialities of Rotch's tables have been enormously 
increased by some of his disciples. I may begin by 
quoting from Ladd 1 a table approved by Rotch himself, 
here very slightly abridged. 



Formula 
No. 


Age. 


Percentages 




Ounces 
per 

meal. 


Number 

of 
meals. 


Interval 


Proteins. 


Fats. | 


Sugar. 


hours. 


I 


Birth 


0.5 


2.0 


5.0 


1.0 


10 


2.0 


II 


2 weeks 


0.5 


2.5 


5.5 


1.5 


10 


2.0 


III 


3 weeks 


0.75 


3.0 


6.0 


2.0 


9 


2.0 


IV 


4 weeks 


1.0 


3.5 i 


6.5 


2.5 


8 


2.0 


V 


6 weeks 


1.0 


4.0 


7.0 


3.0 


8 


2.0 


VI 


2 months 


1.25 


4.0 


7.0 


3.5 


7 


2.5 


VII 


3 months 


1.5 


4.0 


7.0 


4.0 


7 


2.5 


VIII 


4 months 


1.5 


5.0 


7.0 


4.5 


6 


2.5 


IX 


5 months 


1.75 


4.0 


7.0 


5.5 


6 


3.0 


X 


6 months 


2.0 


4.0 


7.0 


6.0 


6 


3.0 


XI 


8 months 


2.5 


4.0 


7.0 


7.0 


6 


3.0 


XII 


10 months 


3.0 


4.0 

1 


6.0 


8.0 


6 


3.0 



Formula 
No. 



Milk ounces. 



Water 
ounces. 



Milk- | Total 
sugar ; ca i or i eS- 



Calories 
per kilo. 



I 


1 . 5 of upper 8 


8.5 


0.4 


125 


36 


II 


2.5 " 8 


12.5 


0.75 


205 


60 


III 


3.5 " 8 


14.5 


1.0 


295 


80 


IV 


5.0 " 8 


15.0 


1.25 


400 


100 


V 


7.0 " S 


17.0 


1.25 


500 


110 


VI 


10.0 " 12 


14.5 


1.25 


510 


100 


VII 


Upper 12 


16.0 


1.25 


580 


100 


VIII 


" 12 


15.0 


1.25 


580 


90 


IX 


16 


17.0 


1.5 


660 


95 


X 


" 20 


16.0 


1.5 


720 


100 


XI 


" 24 


18.0 


1.5 


780 


100 


XII 


40 of whole milk 


S.O 


1.0 


900 


, 110 



130 MILK MODIFICATION 

The first table gives the food requirements. In the 
second table I give the method by which they may be 
met, using top-milk, and adding milk-sugar. I add 
two columns, showing the caloric value of the total 
day's feeding, and the number of calories per kilogram 
of the infant's weight, assuming this to be normal for 
the age. 

In making up these formulas the milk-sugar need 
not be allowed for in calculating the total volume, 
as its molecules occupy the interstices of the fluid, 
increasing the specific gravity, but adding extremely 
little to its bulk. 

A few remarks will indicate how artificial this method 
is and how difficult to work. The tables that I have 
given presuppose milk, containing 3.5 per cent, of 
protein, 4 of fat, and 4.5 of sugar as the raw material 
for modification. If it is lower in proteins and fats 
we have to take a slightly larger quantity of the same 
layer, as indicated in the table, and add a little less 
sugar and water. It is clear that accurate composition 
is impossible outside of a well-managed laboratory, 
where the raw material may be analyzed daily, at 
least for fat, and the ingredients measured precisely. 
The milk laboratory has indeed always been the corner- 
stone of RotchV method, and it cannot be denied 
that his results were better than anything that had 
been previously accomplished, though it is impossible 
to say how much of this was due to his requirement 
of a very pure quality of milk, and how much to the 
percentage system. At any rate, the lapse of time has 
established at least three points of weakness in the 



ADDITION OF FAT 131 

laboratory. The first is the dependence on assistants 
who may or may not be reliable; to err is human, and 
so complicated a procedure, as the filling out of these 
formulas, calls for a high degree of intelligence and 
conscientiousness. The second objection lies in the 
fact, that these laboratories, to realize a profit, must 
remain limited to the large cities; children living 
elsewhere, must have the modified milk transported 
to them, possibly hundreds of miles; it is not uncom- 
mon, in summer, to find the shipment spoiled on arrival, 
an eventuality which either causes illness, through 
not being noticed, or compels the mother to seek a 
probably inferior temporary supply at a local dealer's. 
Last, not least, comes the tendency of the ordinary 
practitioner to interpret the tables in routine fashion, 
with his eyes glued to the age column, and a devout 
faith in the mere figures, that would be admirable 
if it were not so pathetic. It is, indeed, impossible to 
use the tables intelligently without a thorough know- 
ledge of infantile digestive pathology, easy enough in 
the hands of an expert like Rotch, but bristling 
with difficulties to a physician of only moderate 
experience. 

The milk laboratories employ three elements in 
making up the prescribed mixtures: (1) a cream con- 
taining 16 per cent, of fat; (2) separated milk, from 
which the fat has been removed by centrifuging; (3) 
a 20 per cent, solution of milk-sugar. It must be 
remembered that the first and second of these contain 
nearly the same proportions of proteins and sugar, 
approximately those of whole milk. The desired 



132 MILK MODIFICATION 

percentages of the three principal milk ingredients are 
ordered by the attending physician in the form of a 
prescription which is filled out as at a pharmacist's. 
For example, if a mixture with 4 per cent, of fat, 2 per 
cent, of protein, and 7 per cent, of sugar is prescribed, 
the laboratory lets one-fourth of the total consist of 
cream, another fourth of separated milk, which is 
calculated as containing 4 per cent, of proteins, and 
another fourth of the milk-sugar solution, the total 
being made up with water. The result adds up as 
follows : 





Proteins. 


Fats. 


Sugar. 


250 grams cream . 


10 


40 


10 grams 


250 grams milk 


10 




10 " 


250 grams sugar solu- 








tion .... 






50 " 


000 grams total . 


20 


40 


70 " 



Dividing by 10 we obtain the percentages. 

A practical objection to laboratory milk, for persons 
of moderate means, is its costliness, the usual charge 
being a dollar a day. The cost of the raw materials, 
of the very best quality, is less than twenty cents. 
Because of the frequent necessity of long-distance 
transportation, as well as the expense, it became 
imperative to devise some means of bringing per- 
centage-feeding within reach of the masses. This 
led Chapin 1 to work out the method called home 
modification. 

Home modification, carried out under the super- 
vision of a physician, who uses, as general guides, 
two tables more or less like those I have given, solves 



ADDITION OF FAT 133 

the economic problem, and obviates the risk of finding 
the daily supply spoiled, on arrival. Any intelligent 

mother or nurse can learn to make up the day's total 
in an hour or two. The measuring of fluids is best 
done with a Chapin one-ounce dipper, the milk-sugar 
may be reckoned at three level tablespoons to the 
ounce (C. H. Smith). The procedure is as follows: 
The milk is allowed to stand in a cold place for six 
or eight hours; the desired standard of top-milk is 
removed carefully with the dipper, and the required 
quantity of this similarly measured. This is added 
to the stated amount of water, in which the allotment 
of milk-sugar has already been dissolved; milk-sugar 
is more easily dissolved in hot water. Then the entire 
quantity is heated, either to the boiling-point for 
three minutes or to 145° F. (63° C.) for thirty minutes; 
then rapidly cooled and filled into the desired number 
of bottles, which are then placed in the ice-chest. I 
need hardly add that the bottles should be warmed to 
about 90° F. (32° C.) before giving them to the baby; 
this is most easily done by standing them for some 
minutes in very warm water. It is a good rule neither 
to chill nor to heat the bottles too suddenly, if we 
wish to avoid the risk of breakage. 

Aside from what are now regarded as errors in prin- 
ciple, Rotch's tables harbor another defect. The 
caloric value of his mixtures Nos. IV and V, intended 
for the second month of infancy, is rather high for 
artificial feeding, No. VI drops to about the proper 
figure, and there is another drop between Nos. VII 
and VIII that brings the latter a little too low. This 



134 MILK MODIFICATION 

defect is directly connected with the excessively short 
feeding interval in early infancy, and the attempts 
to correct this, as the baby grows older. I might 
say that the short feeding interval mars the whole 
scheme, and that the very small meals only partially 
compensate for this error, which, in the opinion of 
modern pediatrists, vitiates the entire program. 

From the very beginning, physicians had no end of 
trouble with percentage-feeding, in a large proportion 
of their patients; most of these absolute and relative 
failures were wrongly attributed to an excess of casein, 
whereas we now know that the high fat ratios were to 
blame. These experiences led to a desire to vary the 
percentage plan according to the individual, so as to 
give different proportions of the various milk ingre- 
dients; this in turn gave rise to large series of new 
tables. Holt 2 refers to one ambitious author with 
579 formulas, a vivid commentary on the riot of 
mathematics inherent in the consequential study of 
Rotch's method. The difficulties encountered, in 
keeping these masses of figures in mind, or even at 
hand, led Baner to attempt to draw up a simple series 
of formulas, by which the desired composition of the 
food could readily be calculated. 

Baner sets out with the premise that milk contains 
4 per cent, each of proteins, fats, and sugar; the 
apparent inaccuracy not being so very important, 
inasmuch as the fats are stated correctly. The calcu- 
lations become too difficult if we employ many fractions. 
He then presents the following equations: 



ADDITION OF FAT L35 

Let Q = the total quantity desired (in ounces). 

F = the desired percentage of fats. 

S = the desired percentage of sugar. 

P = the desired percentage of proteins. 

M = the required amount of whole milk. 

C = the required amount of cream. 

A = the percentage of fat in the cream minus 4 



Then : 

(1) C= ^ X (F-P), (2) M = 



Q . . ,„ _ _ Q X P 

4 

(S - P) X Q 



(4) S - 



As an illustration, suppose that we desire a quart 
(32 ounces) mixture containing 2 per cent, of proteins, 
3 of fat, and 6 of sugar, using the upper 8 ounces (14 
per cent, top-milk) as a base. By interpolating in 
the above equations we obtain the following: 

32 

(1) C = 1Q X (3 - 2) - 3.2 ounces. 

32 X 2 

(2) M = —7 - 3.2 = 12.8 ounces. 

(3) W = 32 - (3.2 + 12.8) =16 ounces. 

(6 - 2) X 32 

(4) S = - 10 ^ = 1.28 ounces. 



This method is, at least, within the power of the 
ordinary, not mathematically trained mind; the for- 
mulas given by other authors are nearly all more 
complicated, some of them excessively so. Even those 
of Baner are not easy to memorize, and the calculations 
entail more labor than is justified by the results. 

Ten years ago, percentage-feeding had been adopted, 



136 MILK MODIFICATION 

almost universally, by American pediatrists, though it 
found little favor abroad, being considered too compli- 
cated and artificial; in those days only few dissent- 
ing voices were heard on this side of the Atlantic. 
Since then the tide has turned and percentage-feeding 
is now sensibly on the wane, though a substitute there- 
for has not yet been agreed on. The reaction was 
inevitable, because of the serious inherent defects 
of the method; it is interesting to see how it has been 
gradually picked to pieces by the criticism of many 
leading American authorities. 

I have already quoted Holt's 2 opinion of the mathe- 
matical orgies, that have been celebrated by the 
devotees of percentage-feeding; he does not hesitate 
to say that the percentage idea itself has been alto- 
gether overemphasized. Koplik 2 considers the method 
overrefined and essentially artificial, taking no cogni- 
zance of the normal variations in human milk, which 
it seeks to imitate; the laboratories are endeavoring 
to improve on nature, with inferior materials; he 
scouts the idea of trying to benefit a sick infant, by 
giving it a food which is fundamentally unsuitable, 
yet figured out to an amazing nicety. Jacobi 1 breaks 
out into open ridicule of what he calls the gospel of 
top-milk; he also notes that infants thrive on human 
milk of the most varied composition, whereas they 
often will not digest the top-milk percentage mixtures, 
though commanded by the formulas to do so. Chapin, 2 
always a luke-warm follower of the cult, objects to 
the rigidity of the scheme, which permits of no indivi- 
dualization; his opinion is of especial value, because 



ADDITION OF FAT 137 

no pediatrist has given percentage-feeding a more 
thorough trial, whereas Jacobi has always regarded 
it askance. Ladd 1 admits that it is good for healthy 
babies only, and fails in the presence of a digestive 
disturbance; this amounts to at least partial condem- 
nation, for some healthy infants will stand almost 
unlimited abuse of their digestive organs. It is only 
fair to add, that Roteh himself reminds his critics 
that he never recommended his system as a hard and 
fast routine, prescribing such and such formulas for 
this and that age, but drew up his table only as a general 
guide; as to this point, there is no doubt that his 
disciples have outheroded Herod, as invariably happens 
in a new and promising cause, medical or otherwise. 

Still worse is the case of home modification, where 
irregularities in the percentages are inevitable, because 
it is practically impossible to determine the composi- 
tion of the raw material, especially as to its fat con- 
tent. Rotch 2 admitted unevenness in the laboratory 
product, and thought that the results of home modifi- 
cation might be equally reliable — faint praise at best — 
but his recommendation of home modification fails 
to stand the test. Shortly after his publication, Edsall 
and Fife showed that the laboratories, with all their 
faults, produced a far more uniform food, than could 
be made in the home, for the reason just stated. 
Presently, Holt 3 reported a whole series of disastrous 
results from inadvertent high fat feeding, because 
excessively rich milk had been used, under the mis- 
apprehension that it was ordinary grade milk. Only 
a few months later Holt 4 again brought up the subject, 



138 MILK MODIFICATION 

warning practitioners against the use of Jersey milk; 
his 2 still later assertion that this excessive fat feeding 
is due to a misunderstanding of the formulas cannot 
apply to Rotch's own tables, which are relatively 
simple and sufficiently clear. There is no doubt, 
however, that many of Rotch's disciples have suc- 
ceeded in losing themselves in their own mathematical 
mazes. Recently Ladd 3 has again come to the rescue 
by showing that high fat ratios are often tolerated. 
Voices favoring higher fat percentages are now being 
heard from Germany, where, among others, Stolte 2 
and Heim and John 1 plead for a richer infant diet. I 
must mention, however, that they refer to a fat per- 
centage of about 3, whereas the Rotch method calls 
for 4 per cent., a considerable difference. Now, no 
one has ever doubted that some infants can dispose 
of an abundance of fat from the beginning, and most 
of them after six or nine months; this forms no argu- 
ment against the exercise of caution in fat-feeding. It 
is, after all, our main object to avoid failures, not to 
vaunt successes which might have been achieved 
with any method of feeding; by this test alone, the 
high ratio of misadventures, the top-milk gospel has 
forfeited all claim to reverence. 

Another grievous fault of the percentage method, 
already referred to, is the short feeding interval; the 
digestive tract is loaded up with fresh and rich food 
before the preceding meal has been disposed of. If we 
modify the method by introducing the four-hour 
interval it will of course be necessary to recast the 
tables, for the meals that are reduced in number will 



ADDITION OF FAT 139 



have to be increased in hulk. For my part I fail to 
see any benefit from recasting tables that are based 
on the misunderstanding of so many fundamental 
principles of infant-feeding; it seems to me a good 
opportunity to discard the whole ballast of top-milk 
and percentages and return to simpler methods that 
had proved themselves at least as successful, but 
were laid aside because they did not achieve the impos- 
sible, namely, to make of cow's milk an adequate 
substitute for human milk. 

Rotch's tables can be adapted to the four-hour 
interval by slightly modifying the age column, cutting 
out Formula VIII as useless, and allowing a night- 
feeding up to the age of three months. The ratios of 
the ingredients, given in the second table, remain 
unchanged; though they will cause errors of small 
fractions of an ounce, in filling the bottles, these trifling 
irregularities may be disregarded. 

No. of 
feedings. 

6 
6 
6 
6 
6 
5 
5 
5 
5 
5 
5 
(The amount of whole milk in formula XII to be reduced 8 ounces.) 

4. Gartner's Fat-milk. — Gartner's fat-milk is one 
of the favorite German methods of giving a food, low 



No. 


Age. 


per mea 


I 


At birth 


1.75 


II 


2 weeks 


2.5 


III 


4 weeks 


3.0 


IV 


6 weeks 


3.5 


V 


2 months 


4.0 


VI 


3 months 


5.0 


VII 


4 months 


5.5 


IX 


5 months 


6.5 


X 


6 months 


7.0 


XI 


8 months 


8.0 


XII 


10 months 


8.0 



140 MILK MODIFICATION 

in proteins, and fairly rich in fats, the proportions being : 
proteins, 1.5 per cent., fats, 3.0 per cent., and sugar 6.5 
per cent., caloric value about 600 per liter. Gartner's 
modification is prepared by diluting the milk to reduce 
the proportion of casein, centrifuging to increase the fats, 
and adding sugar. Warmly recommended by Escherich, 2 
this product rapidly became popular in Germany, to 
be finally largely discredited, for the same reasons that 
Rotch's method is losing ground here. The reader 
will note the same unwarranted fear of casein, and the 
same confidence in the digestibility of the fat; it stands 
to reason, that the final judgment will also be the 
same. Baginsky 1 sees in it no advantages whatever 
over ordinary milk-dilutions. 

5. Szekely Milk. — Szekely set to work to remove 
the casein thoroughly, and succeeded in doing so by 
subjecting the milk to the action of carbon dioxid 
under a pressure of 25 to 30 atmospheres. The residual 
whey was mixed with half as much of a 10 per cent, 
top-milk, and 1.5 per cent, of sugar was added. The 
resulting composition is: protein, 1.7; fat, 3.3; sugar, 
6.2; salts, 0.6 per cent.; thus it closely resembles 
Gartner's milk. Both Gartner and Szekely milk are 
a little less rich in fat than Rotch's modification, and 
less harmful to just that extent. Although Deutsch 
and Grosz report remarkable successes with Szekely 
milk, its use has not spread widely, because its manu- 
facture requires special and complicated apparatus, 
and is very costly. Both considerations can be dis- 
regarded only if commercial exploitation is the main 
object in view; they are invariably fatal to the prospect 
of general adoption by the masses, as these complicated 



ADDITION OF PROTEIN AND FAT < 141 

and high-priced foods are not sufficiently superior to 
more simple modifications to warrant the financial 
outlay. 

6. Niemann's Modification. — Niemann 2 works along 
new lines by washing butter with water, to remove 
the fatty acids, and adding the butter to a skim milk- 
cereal mixture. The removal of the irritating acids 
should diminish the injurious effects of the cow-milk 
fats. 

ADDITION OF PROTEIN AND FAT. 

Casein-fat-milk. — Heim and John 1 have recognized 
the error of reducing the casein, and, at the same 
time, have desired to retain the fats. Their pro- 
duct bears a name which may conveniently be 
anglicized as casein-fat-milk, the original German 
name being built up of eleven syllables. Heim and 
John secure the casein and fat in the same way, as for 
albumin-milk; they give two formulas for very young 
and older infants, respectively. 

Formula A. 

Remove the curd from § liter of raw whole milk by 
coagulating with rennet at blood heat; stir the curd 
into f liter of hot water; add \ liter of hot whole milk 
and 30 grams of dextrin-maltose. Put the mixture in 
the ice-chest. 

Formula B. 

Remove the curd from \ liter of milk; stir into \ 
liter of water; add \ liter of whole milk and 50 grams 
of dextrin-maltose. 



142 MILK MODIFICATION 

The composition of these two formulas is as follows: 

Formula A. Formula B. 

Proteins 2.1 3.1 per cent. 

Fats 2.4 2.9 

Carbohydrates 4.8 7.7 

Salts 0.3 0.4 " 

Calories 500 . 700 . per liter. 

The above percentages are those given by the authors. 
The proteins of formula A seem a little low, and the 
fat ratios seem to indicate derivation from milk con- 
taining only 3.5 per cent. We may regard the above 
analyses as minimum values. 

Casein-fat-milk has the merit of supplying proteins 
liberally, along with a fat ratio that is not inordinately 
high. The chief argument against its use is, that we 
can obtain similar results by slight dilution with the 
addition of carbohydrates as above. We must note, 
however, that the product here under discussion is 
low in whey proteins and salts, lower than could be 
secured by mere milk dilution. The alteration in the 
proteins is probably immaterial, but the reduction of 
the salts is likely to be beneficial; we shall presently 
see how important a role the salts play in digestive 
disturbances. The reports of other observers who 
have tried this food are just beginning to come in; 
Frank is pleased with his results, though he notes 
imperfect utilization of both proteins and fats; the 
latter is, however, an inherent defect in cow-milk 
feeding, which it is idle to hope to eliminate. Further 
reports would be very desirable, as we may here be 
dealing with a valuable modification. 



ADDITION OF PROTEIN AND FAT 1 13 

Whey-modified-milk. — E. Scliloss 2 lias suggested the 
following milk modification, which he calls whey-modi- 
fied-milk; it is put up according to two formulas, which 
differ so slightly that it will here suffice to give the 
second. He adds together the following ingredients: 

Whole milk 143.0 grams 

20 per cent, cream 143.0 

Dextrin-maltose 50 to 70.0 

Casein (powdered) 5.0 

Potassium carbonate 0.2 

Water 714.0 

The summary of these constituents is as follows : 

Proteins 1.5 per cent. 

Fats 3.4 

Carbohydrates 6 . 3 to 8.3 

Salts 0.4 

Water 88.4 

Calories 620 to 700 per liter. 

Reports show that this mixture must be used with 
discretion. K. Meyer shows that it may lead to rickets, 
but this may be said of any artificial food. Leopold 2 
declares it harmless, but that babies sometimes fail 
to gain on it who afterward may readily be fattened 
with ordinary mixtures. This evidently applies to 
older infants, and his later 3 report confirms its greater 
utility during the first half-year rather than later. 



CHAPTER V. 

MILK MODIFICATION (Continued). 

ADDITION OF CARBOHYDRATES. 

Various carbohydrates have been added to cow's 
milk to bring their ratio up to the standard set by 
human milk, as well as to make up the additional 
deficit caused by dilution; their addition constitutes 
an essential feature of milk modification except where 
it is necessary to keep down the sugar percentage, 
which is the case only when we are confronted with 
the clinical picture of sugar intoxication. We have 
already discussed those modifications, in which the 
proportions of other ingredients, as well as the 
carbohydrates, have been altered, and shall now 
take up only those methods in which nothing 
but carbohydrates and water is added to cow's 
milk. This represents the most ancient method 
of milk modification, the only one that has held 
its ground, more or less, throughout the history of 
pediatrics; it is not always the best, in individual 
cases, but is the one most easily carried out by any 
moderately intelligent mother or nurse, and the one 
best adapted to routine employment. 



ADDITION OF CARBOHYDRATES 1 I") 

This method can be divided into three sub-headings: 
(1) the addition of sugar; (2) the addition of dextrin 
or malt; (3) the addition of starch. 

1. We have discussed quite fully the digestion and 
assimilation of the various sugars, and therefore need 
not repeat those data which are detailed at length 
in Chapter I; we may, however, add a few clinical 
notes. All the sugars agree in favoring lactic acid 
fermentation, though the authorities differ as to which 
leads in this respect; lactose probably ranks first 
and cane-sugar last among the forms commonly 
given. There is quite a general agreement that milk- 
sugar is more laxative than cane-sugar, which has 
a tendency to cause constipation ; an excess of lactose 
causes diarrhea with highly acid evacuations (Talbot 
and Hill) . Calvary 1 and Bendix 1 think that cane-sugar 
is quite as well adapted to general use as milk-sugar, 
with the advantage of much greater cheapness and 
availability. Maltose, by itself, does not show any 
noteworthy superiority over either of the above; the 
excellent results, obtained with malt feeding, are cer- 
tainly not due to the maltose alone. 

2. Dextrin-feeding is also an ancient procedure; 
roasted starch has been given to infants from time 
immemorial, usually mixed with plain milk, and has 
evidently increased the digestibility of that fluid. 
Added to watered milk it undoubtedly saved many 
a baby's life in the dark ages of infant-feeding. Liebig 
was the first to establish a scientific basis for this 
article of food, though he was possessed of little real 
understanding of the action of this substance, which 

10 



146 MILK MODIFICATION 

we ourselves, at this late day, can hardly be said to 
have explained in its entirety. All malted foods contain 
dextrin, and there is reason to believe that their value 
largely depends on their being somewhat complicated; 
such, at least, is the opinion of Usuki and Stolte, 1 who 
believe that a mixture of carbohydrates is more slowly 
absorbed than a pure sugar, and therefore tends to 
check fermentation in the intestine. Southworth 3 ex- 
plains the matter more definitely, by attributing the 
antifermentative action entirely to the dextrin, which 
is not fermentable as such, but only after it has been 
split into maltose, a process that takes place only 
gradually, and in the later stages of digestion. 

Southworth 3 gives analyses of the different dextrin-- 
maltose preparations that are on the market. The 
dry preparations, including Soxhlet's Nahrzucker, 
Loeflund's Nahrmaltose, and Mead & Johnson's 
Dextri-maltose, consist of about half dextrin and half 
maltose; the liquid preparations, including the Malt- 
zyme Co.'s neutral maltose, Loeflund's malt-soup, 
and Borcherdt's malt-soup contain only from 10 to 15 
per cent, of dextrin, and are intended to have boiled 
starch added before using. 

3. The addition of starch is also an ancient procedure. 
When not dextrinized, as described above, it is invari- 
ably boiled; raw starch, as is well known, is almost 
wholly indigestible. We may add the starch to the 
milk before boiling, as is usually done in Germany; 
or we may make up a starch or cereal decoction and 
add it to the milk, such being the prevailing method 
in England and America. 



ADDITION OF CARBOHYDRATES 147 

Starch-feeding has serious and even fatal effects 
if overdone, but has been criticized with undue 
severity, on the theory that young infants cannot split 
starch. We have shown that the diastatic ferments 
are present at birth, and Kerley and Campbell have 
found that some infants can dispose successfully of 
fairly large amounts of starch, nearly an ounce per 
day at one month of age, and three ounces at six 
months. These figures, however, do not apply univer- 
sally, and it is advisable to keep well below them. 
Czerny and Keller have pointed out the risks involved 
in excessive feeding with this carbohydrate; it is apt 
to cause a form of chronic atrophy, called by these 
authors Mehlntihrschaden, i. e., starch-atrophy, char- 
acterized by dryness of the skin and muscular rigidity, 
but relatively slight loss of weight and only moderate 
intestinal disturbance. Starch-atrophy finally proves 
fatal unless the diet is changed; we shall discuss it 
more fully later. This form of atrophy is specially 
frequent in Germany, where starchy baby-foods 
and pap-feeding are very popular with the masses; 
they are less used in this country, where the malted 
foods have the preference; starch-atrophy is there- 
fore less frequent here, though by no means un- 
known. 

Starch-feeding, by adding a cereal decoction to 
milk, is practised here on a very extensive scale, 
but in a somewhat haphazard way, so that Chapin 3 
has deemed it necessary to call for a standardiza- 
tion. He gives the following analytical results as 
to proteins, carbohydrates, and caloric value per 



148 



MILK MODIFICATION 



quart from the addition of graduated quantities of 
cereals : 





Barley-meal. 


Wheat-flour. 


Rolled oats. 


To quart of water. 


















Prot. 


CH. 


Cal. 


Prot. 


CH. 


Cal. 


Prot. 


CH. 


Cal. 


1 ounce 


0.2 


2.1 


90 


0.3 


2.2 


100 


0.3 


1.7 


80 


2 ounces . 


0.4 


4.2 


180 


0.7 


4.3 


200 


0.5 


3.3 


150 


4 " . . . 


0.8 


8.4 


360 


1.3 


8.6 


400 


1.0 


6.7 


310 


6 . . . 


1.2 


12.6 


540 


2.0 


13.0 


600 


1.6 


10.0 


460 


8 " . . . 


1.6 


16.7 


720 


2.6 


17.3 


800 


2.1 


13.4 


620 



The amounts of fat are inconsiderable. The four-, 
six-, and eight-ounce additions can be made only with 
dextrinized flour, which then forms a thick and very 
nutritious gruel. Strictly only the one- and two-ounce 
gruels are under discussion here; by using Robinson's 
patent barley and groats (oatmeal), the decoction can 
be made in twenty to thirty minutes, whereas the crude 
grains must be boiled for several hours, and water 
added to make up the full quart. The favorite milk 
diluents, of this class, are barley and oatmeal, one-half 
or one ounce to the quart; even the former decoction 
contains about 1 per cent, of carbohydrates and fur- 
nishes 40 to 45 calories per quart, a supply that is not 
altogether negligible. 

These thin gruels, despite their very low food value, 
have nevertheless a wide sphere of usefulness, especially 
as they are too dilute to arouse any apprehension of 
causing starch-atrophy. Nearly forty years ago, 
Jacobi 2 showed that the cereals comminuted the 
casein coagula of cow's milk, so that the curd became 



ADDITION OF CARBOHYDRATES 149 

physically similar to that of human milk. He did 
not share the misapprehension, at that time almost 
universal, of the essential indigestibility of cow-milk 
casein, but maintained the trouble was due chiefly, 
if not solely, to mechanical causes, and was not of a 
chemical nature, so that reduction of the curd to 
fine flocculi, instead of massive clots, would remove 
most if not all difficulties. Recent investigations 
and experiences have fully justified this position, 
which is now in a fair way of being universally 
accepted. 

We may now pass on to the several feeding methods 
that involve the addition of carbohydrates to diluted 
milk. 

Jacobi's Method. — Jacobi 2 simply dilutes the milk 
with barley or oatmeal water, using the ounce to the 
pint decoction, and adds cane-sugar to compensate for 
the deficit in carbohydrates. He varies the degree 
of dilution, according to the age of the infant, but 
studiously avoids the error of laying down any hard 
and fast rule; the baby's general condition, especially 
its weight, is the criterion by which the sufficiency 
of the food is judged. This method is so conservative 
that the mistake of overfeeding can hardly be made; 
the defects of the scheme are mostly on the other side, 
because of the low fat percentage and low caloric value 
of these mixtures. * 

Jacobi 2 boils an ounce of barley in a pint of water, 
adds a pinch of salt and strains; then he adds half an 
ounce of sugar, and either half a pint or a pint of boiled 
milk, according to the infant's age. If we reckon 



150 MILK MODIFICATION 

the amount of foodstuffs in his mixtures we obtain 
approximately the following results: 

Formula A. Formula B. 

Proteins 1.5 2.0 per cent. 

Fats 1.3 2.0 

Carbohydrates 6.0 6.0 " 

Salts 0.4 0.5 

Water 90.8 89.5 

Calories 420 . 500 . per liter. 

The caloric value of Formula B can be raised to 
about 560 per liter by adding another half-ounce of 
sugar without rendering the proportion of carbohydrates 
excessive; this would make the caloric value of the 
mixture fairly adequate for the age for which it is 
intended, namely, the second quarter-year, erring, if 
anywhere, on the side of safety. We must remember 
that the caloric control of infant-feeding was unknown 
forty years ago; Jacobi's rather good results were 
entirely the fruit of clinical experience. 

When the barley water and the low fat ratio cause 
constipation, which happens very commonly with this 
diet, oatmeal water, similarly prepared, may be sub- 
stituted for the former; sometimes there is advantage 
in giving a mixture of barley and oatmeal. The slightly 
laxative properties of oatmeal have already been 
referred to. 

In 1876 the short feeding interval was still unques- 
tioned, so that Formula A was divided into eight 
three-ounce portions, and Formula B into six parts 
of five and a half ounces each. After the age of six 
months, Jacobi adds meat broths; then follows a 
gradual transition to whole milk, through progressively 



ADDITION OF CARBOHYDRATES 151 

stronger dilutions, with the addition of bread-crusts 
and meat-juice after ten months. 

The sugar that Jacobi adds to the milk is always 
cane-sugar. When his method was devised, milk-sugar 
was hardly obtainable, and Jacobi was quite confident 
that there was little to choose between these two 
carbohydrates; his standpoint has been fully vindi- 
cated by the recent researches, previously noted. 

When Jacobi introduced his feeding method he did 
so in response to a crying need, for conditions at that 
time were chaotic, w r ith a prevalence of starch-feeding 
which, combined with the impure milk, alone obtainable 
in those days, involved an infant mortality that was 
simply frightful. While this plan represents a decided 
reform, and some of its principles hold good to this 
day, it cannot be denied that both the above formulas 
lean somew 7 hat toward underfeeding. It has been 
pretty well settled that the infant after the first few 
months should get a food-supply equal to 90 or 100 
calories per kilogram of weight if it is to gain steadily 
and normally. These formulas give about twenty 
calories less, even if the full amount of carbohydrates 
is extracted from the cereals, which is a matter of some 
uncertainty. It was largely the recognition of this 
deficiency, soon shown in practical feeding, that paved 
the w T ay for the introduction of the top-milk method, 
which has the tendency to err in the opposite direction. 
We have seen that if the former is the more trying to 
the patience of the attendant, who wishes to see rapid 
progress, the latter is attended with serious dangers 
that seem to me to outweigh its advantages. 



152 



MILK MODIFICATION 



I have always been a faithful adherent of the essential 
features of Jacobi's methods, and have, for a number 
of years, for my private and hospital use, employed 
a table that combines the above principles with a 
slightly higher caloric value, and adapts them to the 
four-hour feeding interval. In view of the low fat 
percentages I deem it advisable to feed six times a 
day during the first few months, which may be accom- 
plished by introducing a night-feeding, or shortening 
the interval to three hours and a half. ^Whereas I 
consider night-feeding absolutely unnecessary, when 
an infant is nursed, it often becomes unavoidable with 
artificial feeding, when the fat ratios must be kept 
low. As a diluent I use weak barley or oatmeal water, 
half an ounce to the quart, which furnishes about 1 
per cent, of starch and an inappreciable amount of 
protein. 



Formula 
No. 


Age. 


Number 

of 
feedings. 


Ounces 

per 

meal. 


Ounces 

of 

milk. 


Ounces 
of sugar. 


Ounces 

of 
barley 
water. 


Calories 
per 
kilo. 


I 


Birth 


6 


1.5 


1.5 


0.25 (i) 


7.5 


25 


II 


1 week 


6 


2.0 


3.0 


0.375 (f) 


9.0 


45 


III 


2 weeks 


6 


2.5 


5.0 


0.5 (i) 


10.0 


55 


IV 


1 month 


6 


3.0 


7.0 


0.75 (I) 


11.0 


65 


V 


2 months 


6 


4.0 


11.0 


1.0 


13.0 


75 


VI 


3 months 


6 


5.0 


15.0 


1.25 (U) 


15.0 


85 


VII 


4 months 


5 


6.0 


18.0 


1.25 


12.0 


85 


VIII 


5 months 


5 


7.0 


22.0 


1.25 


13.0 


90 


IX 


6 months 


5 


8.0 


26.0 


1.25 


14.0 


95 


X 


8 months 


5 


8.0 


30.0 


1.25 


10.0 


100 


XI 


10 months 


5 


8.0 


34.0 


1.0 


6.0 


100 



In the above table the age column is to be em- 
ployed only as a general guide, to be departed from 



ADDITION OF CARBOHYDRATES 



L53 



freely as the requirements of the individual infant 
warrant. Either cane-sugar or milk-sugar may be 
used; I prefer the latter, but the former is cheaper, 
and possibly more convenient for general use, while 
not notably inferior. 

It will be seen that the quantity per meal, while 
somewhat larger than noted in Rotch's tables, is hardly 
up to that ingested by the nursing infant. The caloric 
calculation is so precise as to appear artificial, and 
I frankly plead guilty to the charge, claiming, however, 
that of all artificialities accurate estimation and appor- 
tioning of food value are comparatively pardonable. 

The percentages in these formulas are as follows: 



Number. 

I 

II 

III 

IV 

V 

VI 

VII 

VIII 

IX 

X 

XI 



Protein. 


Fat. 


Carbo- 
hydrates. 


Salts. 


0.7 


0.7 


4.5 


0.13 


1.0 


1.0 


5.1 


0.19 


1.2 


1.3 


5.7 


0.25 


1.4 


1.5 


6.8 


0.30 


1.7 


1.8 


7.0 


0.34 


1.8 


2.0 


7.2 


0.38 


2.0 


2.3 


7.4 


0.43 


2.2 


2.5 


7.1 


0.48 


2.4 


2.7 


6.6 


0.52 


2.7 


3.0 


7.0 


0.57 


3.0 


3.4 


6.6 


0.63 



The reader will see that the fat ratios are not inor- 
dinately high and that the proteins are ample; the salt 
percentages are low during the first months, the dan- 
gerous period. The number of formulas is subject to 
criticism, being not much smaller than is advocated by 
the more moderate adherents of the percentage system. 
I have given so many, largely to satisfy an apparent 
demand; numbers VI and VIII may readily be dis- 



154 



MILK MODIFICATION 



pensed with, and a ten-months infant can often be 
put on whole milk with perfect safety. 

Pfaundler's Method. — Other moves may be recorded 
in the direction of greater simplicity. As an example, I 
give a proposition made by Pfaundler. 1 He mixes one- 
tenth of the body weight of milk with one one-hundredth 
of the body weight of sugar, and dilutes with water up 
to one liter; the total is divided into five meals, and the 
infant allowed to take as much as it chooses. This 
scheme would work out about as follows: 





tc 




S 


Percentage. 






C 




£ 


tn 




Age. 


M 


| 


M 


tr. 

C 




a> 






Xi 










C3 






M 


^ 








& >> 






















£ 


§ 


3 
1 W 


£ 




c3 
O 


<J3 
O 


1 month 


4.0 


0.4 


40 


1.4 


1.6 


5.8 


108 


3 months .... 


6.0 


0.6 


60 


2.1 


2.4 


8.7 


108 


6 months .... 


7.5 


0.75 


75 


2.6 


3.0 


10.9 1 108 



Pfaundler's plan is open to several criticisms. In 
the first place there is an excess of calories, in other 
words, an excess of food. In earliest infancy this is 
automatically corrected by the circumstance that 
the infant will not take more than half or two-thirds 
of the allotted quantity; later on, when it empties the 
bottles, it certainly obtains an excess of carbohydrates, 
the figure for the age of six months being so high as 
to involve some risk of sugar intoxication. The per- 
centages of proteins and fats are about right. Pfaundler 
gives malt, by preference, in early infancy, which 
we shall presently recognize as a good feature; his 



ADDITION OF CARBOHYDRATES 155 

recommendation of large proportions of starch, one- 
third or more of the large total of carbohydrates, in 
later infancy, must be regarded as an error, inviting 
the clinical picture of starch-atrophy, as the quantity, 
recommended by him, runs close to the limit of infantile 
starch tolerance. 

This scheme, furthermore, is too much on the rough- 
and-ready order; it is practically admitted to be such 
by the author, who wishes to make things easy for the 
practitioner, in so many words, and evidently desires 
to achieve a rapid gain in weight, so that all parties 
will be satisfied. Considering these aspects of the 
case, this method is not likely to commend itself to 
the careful pediatrist, and I cannot find any evidence 
in the literature that it is likely to become popular; 
it seems to be decidedly a step backward. 

Keller's Method. — Keller's 3 method of milk modifi- 
cation, devised by him for the feeding of sick infants, 
but by no means restricted to this narrow field, is 
essentially a revival of Liebig's, but modernized, and 
most ingeniously adapted to infants, who have diffi- 
culties in digesting the fats of cow's milk. The basis 
of his plan lies in the employment of w T hat he calls 
malt-soup, a preparation now put on the market by 
several manufacturers. Malt-soup, made along the 
lines laid down by Liebig, contains about 55 per 
cent, of maltose, 15 of dextrin, and 1.1 of potassium 
carbonate, besides active diastase. Keller's mixture 
is made as follows: An ounce and a half (50 grams) of 
wheat flour are thoroughly stirred into eleven ounces 
(J liter) of milk and strained; then three ounces (100 



156 MILK MODIFICATION 

grams) of malt-soup are added to twenty-two ounces 
(| liter) of water at 122° F. (50° C); the two mixtures 
are then thoroughly combined, during which process a 
part at least of the wheat starch is dextrinized; then 
the whole is boiled for three or four minutes, to sterilize 
it and destroy the diastase. The resulting compound 
presents the following analysis: 

Proteins (^ w 1.1 per cent. 

[ vegetable 0.7 

Fats 1.2 

Carbohydrates 11.4 

Salts 0.4 

Water 85.2 

Its caloric value is about 630 per liter, 19 per ounce. 

Some points in this analysis are worth discussing 
more in detail. The vegetable protein derived from 
the flour cannot be regarded as quite equivalent to the 
milk protein, as its digestibility is somewhat inferior. 
The ratio of potash is high, about half of the total 
salts, owing to the potassium carbonate content of 
the malt-soup; this is added for the purpose of com- 
bating the acidosis that is always more or less present 
when the fat metabolism is impaired, this last being 
the usual indication for feeding with Keller's modi- 
fication. The fat ratio is kept exceedingly low to meet 
the same indication, and the high carbohydrate content 
is intended to make up for the deficit in fat. 

Keller's mixture is of great value in obstinate cases 
of cow-milk indigestion, partly because of its extremely 
low fat content, partly because of its alkalinity. More- 
over, the high proportion of carbohydrates is presented 
in as unobjectionable a form as possible, Czerny 



ADDITION OF CARBOHYDRATES 157 

and Keller claiming that the tolerance for malt is 
twice as great as for either milk-sugar or cane-sugar. 
Without this large percentage of carbohydrates the 
caloric value of the mixture would be very inadequate. 

Babies fed on Keller's mixture usually gain in weight 
in a very satisfactory way, but the gain consists too 
exlusively of fat; the other tissues are more or less 
starved and, if this food is continued for more than 
two or three months, the low fat and protein ratios 
are quite sure to lead to rickets. The absorption of 
the small amount of fat speedily becomes satisfactory; 
the stools soon lose their soapy character, partly because 
of the action of the malt (Freund 1 ), partly on account 
of the reduction of the calcium waste. The last is 
reduced by two factors: (1) the alkaline character of 
the food, potassium being particularly effective in this 
respect (Dubois and Stolte); and (2) because there is 
little free fatty acid to bind the calcium. Neverthe- 
less, owing chiefly to the very small supply, less than 
the normal amounts of both calcium and phosphorus 
are absorbed, so that the liability to rickets is readily 
accounted for. Scurvy has also been observed after 
continued feeding with Keller's modification (Rosen- 
thal). 

Through its success in cases of atrophy and fat- 
indigestion, Keller's idea, suitably modified, has led 
to a wide extension of malt feeding. Observing the 
easy digestibility of the malt mixture, pediatrists 
have endeavored to apply the principle later on, when 
ordinary feeding, with abundant proteins and fats, 
must again be given. These attempts have turned 



158 MILK MODIFICATION 

out most successfully; the addition of malt to the 
formulas, in place of milk-sugar or cane-sugar, has 
been wholly beneficial; the restraint on fermentation, 
and consequent improved fat absorption, caused by 
the mixture of dextrin and maltose, has been so evident 
as to lead to a very extensive employment of this 
substitute for the ordinary sugars; it is likely to become 
a permanent addition to our means of milk modifi- 
cation. 

I make it a rule to give the ordinary formula with 
dextrin-maltose whenever the usual milk- or cane- 
sugar mixtures seem to cause excessive fermentation 
and colic, or are attended with the evacuation of soap 
stools. I decidedly prefer this, as a preliminary 
measure, to going over at once to some very low fat 
combination, which can only be a temporary make- 
shift at best. I also find dextrin-maltose an excellent 
addition to albumin-milk when the first object of that 
food has been achieved and a gain in weight is desired ; 
in this way I have succeeded in feeding albumin-milk 
far beyond the period usually advised, with highly 
gratifying results. 

I must not fail to mention that the dextrin-maltose 
preparations are put up with and without the addition 
of 2 per cent, of sodium chlorid. It is rarely advisable 
to add this salt to the infant's food, as sodium chlorid 
has not by any means the same physiological action 
as the potassium carbonate added to Keller's malt 
soup. I regard the malt preparations without ^salt as 
decidedly preferable for our purpose. 



CALORIC FEEDING L59 



CALORIC FEEDING. 



The disproportion between the difficulties in mak- 
ing up the mixtures described in these two chap- 
ters and the results achieved by feeding them has 
led many pediatrists to cast about for something 
both simpler and more effective, and some of us 
profess to have found the philosopher's stone in what 
they call caloric feeding. Unfortunately for this 
new movement, it is only too easy to prove that it 
begs the question, and therefore cannot lay claim to 
the dignity of being enrolled as one of the many new 
feeding methods. It is very much as if we were to call 
the baby-scales a feeding method; in fact, caloric 
estimation is not even so good a guide, as it merely 
represents a theory, whereas the scales show results. 
This is very clearly pointed out by Chapin 4 and the 
Heubners, who show that there may be no gain in 
weight on an apparently ample provision of calories 
in the food. Koplik 2 remarks that all our mathematical 
data fail to allow for the great variations in the utili- 
zation of cow's milk even by apparently healthy infants. 
These facts are indeed so obvious that only a very 
uncritical observer could ever be misled into adopting 
a mere physiological theory as an absolute rule in so 
complicated and difficult a matter as the artificial 
feeding of infants. Ladd 2 and Lamb were unques- 
tionably correct in insisting, even in the early days 
of this propaganda, that the caloric standard should 
never be elevated to a method, but only utilized as a 
guide, a check on the existing modes of feeding, but 



160 MILK MODIFICATION 

inferior, even in this respect, to the careful obser- 
vation of the infant's digestive functions and body 
weight. 

If I have, nevertheless, given in minute detail the 
caloric value of the various milk-mixtures it has been 
done for the sake of completeness and to satisfy a 
popular demand. A reference manual should aim to 
give every aspect of the subject; this does not by any 
means imply an indorsement of every idea that is 
presented. There can be no harm in stating the theo- 
retical food value of a dietary if we bear in mind that 
the final test of its usefulness lies in the results achieved 
and not in our anticipations. 

We may now pass on to those methods of milk modi- 
fication which consist in adding foreign substances 
to cow's milk. 

THE ADDITION OF ALKALIES. 

This is an old method of modifying milk, and 
is based on two errors; the first is the belief that 
human milk is alkaline, whereas it is practically 
neutral (amphoteric) — faintly acid to phenolphthalein 
(Southworth 4 ) . The second error lies in the hasty 
conclusion that the acidity of cow's milk is harmful; 
we now know that fairly large amounts of lactic acid 
may even be beneficial. 

The alkalies most often added are lime water, sodium 
bicarbonate, and sodium citrate. The addition of 
potassium carbonate has already been discussed under 
the head of Keller's malt-feeding, and serves a special 



THE ADDITION OF ALKALIES 161 

purpose, apart from the mere desire to alkalize the 
food; we need not therefore consider that salt further 
in this connection. 

Lime-water is usually added in the proportion of 5 
per cent, of the amount of milk, not the total amount 
of the mixture. The sodium salts are added in the 
proportion of 1 grain to the ounce of milk, 2 grams 
to the liter (quart). It will be seen that the addition 
to the original milk salts is considerable in the latter 
case, an amount of sodium being added, approximately, 
equal to that already present. Lime water is so dilute 
that the addition of calcium to the milk is quite insig- 
nificant. 

Among the earliest and best studies on this question 
is a short article by Wright. He found that the addition 
of small amounts of sodium citrate, say 0.2 per cent., 
to the milk caused precipitation of a part of the milk 
calcium and rendered the subsequent coagulation of 
the casein finer, more like that of human milk. Larger 
additions of sodium citrate, from 0.5 per cent, upward, 
entirely inhibited the coagulation of the casein. The 
same result is obtained by the addition of the same 
proportion of sodium bicarbonate. 

The action of lime water is somewhat different, 
as it cannot, of course, precipitate calcium. It has, 
however, a similar action on the casein coagulation, 
causing it to be finely subdivided, if added in the propor- 
tion of 5 per cent., and inhibiting it if 12.5 per cent, 
are added. 

To put it briefly, these alkalies, in the stated pro- 
portions, either delay or inhibit the gastric digestion of 
11 



162 MILK MODIFICATION 

casein, relegating its disintegration to the intestines. 
This is agreed upon by all clinicians, but is not so very 
important after all, because the proteolysis in the 
stomach is relatively unimportant in any event, com- 
pared to the tryptic process in the small intestine. 
The question naturally arises, what is the real object 
achieved by adding alkalies to the food? The answer 
given by Chapin, 5 Southworth, 4 and Pisek is: practic- 
ally none at all, save in those cases, where an alkali 
is especially indicated. We have seen, however, that 
potassium carbonate is to be preferred, in meeting 
this indication, so that it is doubtful if the addition 
of lime or the sodium salts is ever required. As to the 
production of a fine casein coagulum, the cereals do 
this quite as effectively without impairing the digest- 
ibility of that protein (Chapin 5 ). 

By thus disposing of the alkalies as a class we also 
do away with the claims of sodium citrate, the employ- 
ment of which recently threatened to become a fad. 
It came into prominent notice in 1903, being highly 
recommended by Variot 3 and his school, and imme- 
diately taken up by Poynton; thence its popularity 
rapidly extended to this country, very soon leading 
to the adverse reports cited above. 

ADDITION OF FERMENTS. 

There have been many attempts made to render 
milk more digestible by adding ferments. These fer- 
ments may be conveniently divided into two groups, 
the proteolytic and the glycolytic, the employment 



ADDITION OF FERMENTS 163 

of which is based, respectively, on two entirely dif- 
ferent theories. 

1. Proteolytic Ferments. — These are added on the 
erroneous theory that casein is a frequent cause of 
indigestion; therefore, to render it more absorbable, 
pepsin, rennet, and trypsin have been added to the 
milk or milk-mixtures. Sometimes the milk has been 
modified by the addition of one of the various peptone 
preparations that are on the market, or these prepara- 
tions have been given in water or gruel. The reader 
must be careful to remember that by adding merely 
pepsin or rennin, the casein is not peptonized, but 
only converted into paracasein; to produce true 
peptonization the action of the pepsin must be pro- 
longed for hours, or trypsin (or pancreatic extract) 
used. We have already noted that very little pro- 
tein is rendered absorbable by the gastric secretion 
alone. 

One way of peptonizing milk is to add a portion of 
the contents of a so-called peptonizing-tube, shake 
well, and heat to 100° F. (38° C), for a few minutes; 
this method is extremely popular in this country, but 
it remains questionable whether much of the milk 
protein is really peptonized. Rennet is a popular 
addition in Europe, largely in the form of a proprietary 
preparation called pegnin; the reports on this modifi- 
cation of milk vary in their tenor, but mostly agree 
with Reinach and Oppler in praising it very faintly, 
and advising against its employment in early infancy, 
the very period at which it occasionally seems indi- 
cated bv clinical conditions. The actions of rennet 



164 MILK MODIFICATION 

and trypsin are combined in the German preparation 
called Backhaus-milk, which has come into very 
extensive use. As to this also the best authorities are 
far from enthusiastic, especially as regards very young 
babies; I cite merely Baginsky 1 and Thiemich 2 as 
observers whose opinions cannot fail to carry weight. 
Philips 2 reports very inferior results from the addition 
of 0.2 to 0.5 gram each of pepsin, pankreon (a pancreatic 
extract), and emulsin to the daily food allowance; this 
combination had been highly recommended by Siegert. 1 
Siegert's 2 later attempt to discredit Philips' criticism 
has been finally disposed of by Czerny, 3 who attrib- 
utes the whole idea of proteolytic ferment-feeding to 
a misapprehension of the remarks on the digestive 
ferments by Czerny and Keller; these authors had 
never meant to imply that any improvement in infant- 
feeding could be effected along this line. 

It remains for us to discuss the direct administra- 
tion of peptones. Somatose may be regarded as the 
type of the peptone powders containing 80 per cent, 
of so-called peptones (mostly albumoses). The liquid 
peptone (albumose) preparations are quite numerous; 
they all contain about 15 per cent, of alcohol, without 
which they would putrefy, and rarely more than 5 per 
cent, of the product, after which they are named. 
They thus are really equivalent to fairly strong wines, 
containing a little albumose, abundant extractives, 
and usually a little sugar. Their value as infant foods 
may be readily gauged from their published analyses, 
and the practitioner will do best by regarding them as 
alcoholic stimulants, plus a food value less than that of 



ADDITION OF FERMENTS 165 

equal quantities of milk. To this the contained alcohol 
adds about thirty calories to the ounce, but alcohol 
is now generally regarded as a specially undesirable 
caloric vehicle, even in small doses, except perhaps 
in febrile conditions, and this remark applies most 
particularly to infants; in spite of its high caloric 
value, alcohol is in no sense a food, and the real amount 
of nourishment to be expected from teaspoonfuls or 
even tablespoonfuls of these so-called peptonoids may 
be readily conceived as quite trifling. 

Recapitulating, the results obtained through the 
administration of the proteolytic ferments and their 
products are very far from brilliant, and fortunately 
they are rarely indicated, except occasionally in fevers, 
when the last-mentioned group have a certain field 
of usefulness, which I do not hesitate to attribute 
chiefly to their content of alcohol. Their employment 
should never be more than occasional and temporary, 
and with regard to their medicinal qualities, rather 
than their ostensible food value. 

2. Glycolytic Ferments. — The term glycolytic ferments 
must here be construed broadly to include glycolytic 
microorganisms as well as ferments in the modern 
sense. This is merely a matter of precision, for these 
methods date back to a time when this distinction 
was impossible; the inventors of all these processes 
thought that they were employing ferments as we 
now understand the term. We have already discussed 
the most frequently employed ferment of this class 
in considering malt-feeding; diastase is, however, not 
properly a glycolytic but an amylolytic ferment; all 



166 MILK MODIFICATION 

the strictly glycolytic ferments that are employed in 
modifying milk are living microorganisms. 

Lactic Acid Fermentation. — Lactic acid is formed 
from milk-sugar by the metabolic processes of any of 
the several varieties of the lactic-acid bacillus, the 
use of which is extreme^ ancient, having been prac- 
tised in the Orient since prehistoric times. In western 
countries milk has been allowed to become acidified 
spontaneously, in manufacturing butter, though the 
modern methods of butter-making start the process 
with a bacillary culture. In the East, artificially 
acidified milk, produced by transplantation of the 
bacilli, has always been a popular article of diet. 

Much trouble has arisen from the confusion of 
acidified milk with buttermilk; both are the result 
of the action of lactic acid bacilli, but their manipu- 
lation has been totally different. Acidified milk is 
still whole milk, and the bacilli are allowed to remain 
in it alive and active. Buttermilk has had the clotted 
fats extracted by churning and the residue sterilized 
by heat. The latter, fully discussed in the preceding 
chapter, is practically skim milk, containing free 
lactic acid, but destitute of any ferment activity. The 
former is a complete food, with intact and vigorous 
fermentative capacity. 

Introduced into this country by Dadirrian, in 1885, 
as matzoon, the Oriental type of acidified milk steadily 
gained in popularity, but only as a semimedicinal 
beverage, until the publications of Metchnikoff started 
a wave of enthusiasm for this food. Metchnikoff 
recognized the profound influence of living lactic acid 



ADDITION OF FERMENTS 167 

bacilli on the fermentative processes in the intestinal 
canal; active formation of lactic acid interferes with 
the growth of putrefactive bacteria and materially 
restricts the production of many substances that are 
both irritating and toxic. We have seen that, in the 
normal infant, these bodies are, in any case, reduced 
to a minimum; the intestinal contents of a healthy 
infant show the action of few germs, except the pre- 
dominating lactic-acid bacillus. In the presence of 
certain pathological processes, however, the situation 
is very different, and the implantation of living acidify- 
ing bacilli may often be necessary, or at least useful, 
in restoring the fermentative processes, in the digestive 
tract, to the normal type. 

Matzoon, also called zoolak or yoghourt, presents 
the following composition : 

Proteins 3.5 per cent. 

Fats 3.5 

Milk-sugar 3.7 

Lactic acid 0.9 

Salts 0.7 

Alcohol 0.1 

Water 87.6 

It thus consists of whole milk, with about a fifth 
of the milk-sugar converted into lactic acid and a 
minute and negligible trace of alcohol. 

Bacteriologists differentiate several types of lactic- 
acid bacilli, and some discussion has arisen as to which 
yield the best results. Matzoon is fermented by the 
variety bulgaricus, but Rotch and Kendall think that 
the variety acidophilus may be even better. The 
probability is that there is little choice among them, 



168 MILK MODIFICATION 

provided they are in pure culture and uncontaminated 
with other germs. 

Matzoon, as described, is hardly a suitable food 
for young infants, because it has the defect of ordinary 
cow's milk, namely, a high percentage of fat. In early 
life it still remains necessary to dilute the milk, before 
or after adding the pure culture of lactic-acid bacilli; 
if we proceed in this manner we obtain a food that 
has a wide range of usefulness. Thus, Morse and 
Bowditch found acidified milk far superior to butter- 
milk in fermentative disturbances; good results are 
also reported by Dunn. 1 Brady 1 goes into the matter 
quite deeply; he too notes the great superiority of 
acidified milk containing live germs. He first boils 
the milk, to obtain a germ-free soil, then adds the 
pure bacillus culture and lets the milk stand in a warm 
room for twenty-four hours, finally modifying with 
barley water and cane-sugar, as in ordinary formula- 
feeding. This mixture must be entirely used up within 
a day, as it cannot be made to keep indefinitely; after 
the lactic-acid fermentation has reached a certain 
point, putrefactive bacteria gradually begin to grow in 
the milk and, in the course of time, gain the upper hand. 

Despite these recommendations, the employment 
of acidified milk has gained ground but slowly, and 
many authors confess to disappointment. This is 
largely due to the unreliability of many of the market 
cultures of the bacilli, especially such as are sold in 
tablet form; some of these tablets consist entirely - 
or chiefly of dead germs, which of course are utterly 
worthless for our purpose. The Journal of the American 



ADDITION OF FERMENTS 169 

Medical Association for December 13, L913, gives a 

list of such preparations as are active; the liquid 
cultures are decidedly more trustworthy than the 
tablets, but, from their very nature, neither will keep 
alive indefinitely. 

Alcoholic Fermentation. — By adding yeast to some- 
what diluted milk, and allowing the mixture to 
stand in a warm place, we obtain the product know r n 
in this country as kumyss, which is not the same as 
Oriental kumyss. The composition of American 
kumyss is as follows : 

Proteins 2.0 per cent. 

Fats 1.9 

Sugar 3.3 

Alcohol .0.6 

Acids (free) 0.3 

Salts 0.4 

Carbon dioxid 0.4 " 

Water 91.1 

Kumyss contains about 430 calories per liter, of 
which 40 are credited to the contained alcohol. It 
is therefore a decidedly insufficient food, and has 
yielded no noteworthy results in infant feeding. It 
may, however, claim a limited field of usefulness in 
febrile conditions, especially in older infants, where a 
moderately low fat and sugar percentage is indicated. 

Kefir, or Oriental kumyss, is a product of mixed 
yeast and lactic-acid fermentation, with the following 
composition (according to Konig) : 

Proteins 2.7 per cent. 

Fats 1.8 

Sugar 4.1 

Alcohol 1.1 

Lactic acid 0.6 

Salts 0.4 

Water 89.3 



170 MILK MODIFICATION 

This kefir lias evidently been made from partly 
skimmed milk. The ratio of lactic acid is often lower 
than given in the above analysis, and therefore hardly 
sufficient to influence the intestinal fermentative 
processes. The alcohol is altogether objectionable. 
We must also note that kefir is a very variable product 
and that the percentages of the ingredients are subject 
to considerable fluctuations, so that the actual food 
value is a rather uncertain quantity. 

Peiser 2 advises the use of an alkalized kefir in 
intestinal disorders. He dilutes with water, half and 
half, and adds 0.1 per cent, of sodium carbonate; the 
resulting mixture containing the following: 

Proteins 1.5 per cent. 

Fats 1.7 

Sugar 1.5 

Salts 0.2 

Lactic acid 0.2 

Water 94.9 

The caloric value is only about 280 per liter, a semi- 
starvation diet; most of the reported effect seems to 
be due to this circumstance, and this product is evi- 
dently adapted to only very temporary use. 

We must now consider some milk modifications 
that do not come under any of the stated headings, 
but which, nevertheless, present some claim to our con- 
sideration. 

HOMOGENIZED MILK. 

Now that the dread of the indigestibility of casein 
has given way to the well-justified fear of the milk 
fat, attention has been given to attempts to modify 



BABY FOODS 171 

the latter constituent, so as to render it more absorb- 
able. This has led to the manufacture of what is 
called homogenized milk, in which is presented an 
endeavor to increase the digestibility of the fats 
by reducing the size of the milk globules; this is 
accomplished by nebulizing the milk with a high- 
pressure spray apparatus. As Chevalier has shown, 
the globules are thereby not only reduced in size, 
but are broken up and deprived of their envelopes; 
the result is a product, that is far more digestible 
than unaltered milk, but has the disadvantage of 
spoiling readily. 

The employment of homogenized milk spread rapidly 
throughout Belgium, France, and Switzerland, but 
destructive criticism was not long in making itself 
felt. Bernheim-Karrer, Bourdillon, and others pre- 
sently reported numerous cases of scurvy resulting 
from this diet, and Chevalier's insistence that this 
untoward result w-as due to decomposition of the 
food did not offset their criticism, since he admitted 
its poor keeping qualities. Birk 3 is one of the few 
Germans w T ho have tried it, and he has found it not 
sufficiently useful to compensate for the above-men- 
tioned risk. 

BABY FOODS. 

We have already discussed the malt and cereal 
preparations, called infant foods, that are intended 
only as additions to milk, and as such often serve a 
very useful purpose. The following remarks apply 
to such products as are recommended by the manu- 



172 MILK MODIFICATION 

facturers, and unfortunately also by some physicians, 
as complete infant foods, requiring only the addition 
of water. I select the well-known article called Nestle's 
food as the type; it consists of desiccated milk, baked 
flour, and 30 per cent, of cane-sugar; more than a 
third of the total carbohydrate is present in the form 
of starch. A dilution of 5 ounces of this food with a 
quart of water yields the following analysis: 

Proteins 2.1 per cent. 

Fats 1.0 

Carbohydrates 14.7 " 

Salts 0.3 

Water 81.9 

The caloric value of this mixture is about 750 per 
liter. 

The proteins might appear to be present in fairly 
ample ratio, but, being largely vegetable proteins, 
are subject to some discount for imperfect absorption. 
The fats are so wofully deficient that any prolonged 
employment of this food is out of the question. The 
carbohydrates are present in great excess, and the 
starch content amounts to more than o per cent. We 
cannot conceive of a food more likely, from continued 
use, to invite the starch-atrophy described by Czerny 
and Keller; the risk of rickets and scurvy is great, and 
the former of these may be expected with certainty, if 
Nestle's food is given for a few months. We shall 
presently see that the development of acidosis is greatly 
favored by the low fat percentage on the one hand 
and the overloading with unassimilable carbohydrates 
on the other. 



BABY FOODS L73 

Imperial Granum is an especially bad infant food, 
being practically pure flour; the recommendation of 
this food as a substitute for breast-milk cannot be 
too severely reprehended, and is almost certain to 
lead to a fatal result from starch-atrophy. 

Less objectionable, but still entirely unsuitable 
for infants, are such products as Horlick's malted 
milk. This has about the same caloric value as 
Nestle's food, a little more protein, still less fat, and 
the same amount of carbohydrates, but no undextrin- 
ized starch. There is less danger of atrophy, but the 
prospect of acc-uiring rickets, and especially scurvy, 
is excellent. We have already noted the serious and 
fundamental objections to desiccated milk as an infant 
food, and shall have more to say on this subject later 
on; for the present it will suffice to remark that the 
employment of any such food as the regular diet of 
an infant is an error of the grossest description. These 
preparations have always been the most fertile source 
of the hundreds of cases of fat rickets that still throng 
our dispensaries, and were formerly common in private 
practice as well; the danger of feeding these products 
to babies is even enhanced by their ample caloric value. 
The infants gain in weight regularly and sometimes 
more rapidly than normal, unless digestive troubles 
or starch-atrophy set in, as is often the case; their 
general development does not, however, keep pace with 
the gain in subcutaneous fat, and the other tissues, 
especially the muscular and osseous systems, are apt 
to be in very poor condition. 



CHAPTER VI. 
INFANT FOODS OTHER THAN MILK. 

Aside from milk and milk modifications, many 
other substances and preparations have been suggested 
and used for feeding infants. In the following pages 
I shall discuss merely a few of these, selecting such as 
have been widely employed, or recommended by good 
authorities. 

Beef-juice. — This may be obtained at home by ex- 
pressing the juice of raw or slightly broiled beef, or 
may be bought in the shops, ready for use. There 
are two ways of preparing this food. We may soak 
a pound of finely chopped beef in half a pint of water, 
for six to twelve hours, keeping it on ice, and then 
express the juice by twisting in coarse muslin. The 
result is about eight ounces of a fluid, containing the 
following ingredients: 

Proteins 3.0 per cent. 

Extractives 2.0 " 

Salts 0.2 

Water 94.8 

According to the second method a pound of lightly 
broiled steak is squeezed in a meat-press; we thereby 
obtain only about three ounces of a fluid, of similar 
composition, save for about 1 per cent, additional 



MEAT BROTHS 17.") 

extractives and 0.6 per cent, of fat. The former pro- 
cess is evidently the more economical. As foods, both 
have little value, not more than 4 or 5 calories to the 
ounce, with the disadvantage of furnishing only 
proteins and extractives, no carbohydrates, and little 
or no fat. The so-called extractives are purin bodies, 
of some little use in stimulating the gastric secretion, 
but of low food value, and most probably rather harmful 
in their influence on the general metabolism. Perhaps 
no foodstuff has been so persistently and unjustifiably 
overrated as the article here under consideration. 

The commercial beef -juice preparations, represented 
by Valentine's, differ from the above, only in being 
about three times as concentrated. They contain an 
enormous excess of salts (about 10 per cent.), which 
renders them actually poisonous to infants, even when 
well diluted. 

Beef Extract. — Beef extract is simply concentrated 
beef -juice, with a slightly higher proportion of extrac- 
tives and a very large amount of salts; the objections 
made to beef -juice, apply here with even greater 
force. Feeding with beef extract is not only a method 
of almost complete starvation, but is more than likely 
to induce the condition known as salt-fever in a very 
short time. 

Meat Broths. — When well made, of beef, mutton, or 
chicken, meat broths are exactly equivalent to dilute 
meat-extracts; when badly made, as often happens, 
they are nearly pure salt solutions. The remarks 
made in connection with beef extract apply here 
equally. The food value of broths may, however, 



176 INFANT FOODS OTHER THAN MILK 

be materially increased by the addition of cereals, 
such as barley or rice, and in that case they may 
sometimes be of use for older infants, if care be taken 
to give them strained and in small quantities, not 
exceeding four ounces at a time, nor replacing other 
more nutritious food. 

Broths were formerly highly extolled as infant 
foods, either in cases of milk-intolerance, or as supple- 
ments to milk in the second half of the first year. 
It is remarkable how the leading pediatrists of the 
last generation agreed in recommending these feebly 
nutritious and even harmful foods, and it is gratifying 
to note that their vogue has passed. They are still 
casually mentioned in the text-books, but chiefly for 
the sake of completeness; all the authorities of today 
give them a very low rating. 

Eggs. — Because of its lecithin content and the wide- 
spread but exaggerated belief in the value of lecithin 
as a source of available phosphorus, the yolk of eggs 
has been recommended by many authors, among whom 
I may mention Miiller 2 abroad and Stern in this 
country. McCollum and Davis show the biochemical 
resemblance between milk-fat and egg-fat, both differ- 
ing markedly from the ordinary fats. Stern calls atten- 
tion to the high ratio of fat in the yolk of eggs, namely, 
48 per cent., claiming that yolk-fat is more digestible 
than cow-milk fat, but hardly proving his claim. Other 
authors may be mentioned who do not share this en- 
thusiasm; Vogt, for example, does not consider the 
yolk of eggs in any way superior to milk ; he finds that 
infants that are fed on it finally cease to gain in weight 
and become anemic. As to the metabolic value of 



EGGS 177 

lecithin, we need only to refer again to Berg's investiga- 
tions, mentioned in the first chapter of this book. It 
is indeed very questionable if the yolk of eggs forms a 
very important addition to our list of infant foods. 

Egg-albumen-water was at one lime a favorite 
food in severe intestinal disturbances. It was long 
ago recognized that these cases tolerated a starvation 
diet but a very short time, a day or two, and a protein 
solution was even then regarded as a good food to begin 
with. Holt 1 gives the following recipe for albumen- 
water: the white of one fresh egg, one-half pint of 
water, a little salt, one teaspoonful of brandy; shake 
thoroughly. This mixture would contain about 1.5 per 
cent, of proteins and 0.8 of alcohol. I always added the 
white of an egg, beaten up, to a pint of barley water, 
with a little sugar added, omitting the alcohol; this 
gave the rather low ratio of 0.8 per cent, of protein, 
which was more than compensated for by the addition 
of about 1 per cent, of sugar and the same of cereal 
starch. The invention of albumin-milk has rendered 
egg-albumen-water quite superfluous, so that most 
modern text-books mention it quite casually. 

In connection with the feeding of eggs, special 
interest attaches to a phenomenon long since familiar 
to observant practitioners, but first explained by 
O. M. Schloss, namely, the intolerance to egg-albumen 
exhibited by a considerable number of persons, includ- 
ing infants. There is a good deal of evidence to show 
that this intolerance is, at least in some cases, of an 
anaphylactic nature, so that experiments in feeding 
infants with either the yolk or the white of eggs are 
12 



178 INFANT FOODS OTHER THAN MILK 

not unlikely to lead to very acute disturbances, in a 
certain proportion of cases. Lust 4 observes that 
the limit of tolerance for the white of eggs by healthy 
infants is about 60 grams (the white of two eggs) per 
day, and much lower in the presence of gastrointes- 
tinal disorders; albuminuria sets in much more readily 
from this food than from milk proteins, so that we have 
another very good argument against this form of 
nourishment. 

Leguminous Vegetables. — The dried leguminous seeds 
(peas, beans, and lentils) contain about 25 per cent, 
of proteins, 2 of fats, 60 of carbohydrates, 3 of salts, 
and 10 per cent, of water, with the extraordinarily 
high food value of 115 calories per ounce. A number 
of attempts have been made to utilize them in infant 
feeding. Edsall and Miller added a 10 per cent, 
dextrinized bean-soup to the ordinary milk mixtures in 
the proportion of one part of bean-soup to three of 
milk; this was equivalent to adding about 0.7 per cent, 
of protein and 1.5 of dextrin to the food. This com- 
bination seemed to be of some value in infants that 
failed to get along on the regular formulas ; some of the 
benefit undoubtedly was attributable to the dextrin, 
the role of the vegetable protein being rather doubtful. 
These investigations should be followed up, especially 
along the lines of the protein metabolism; we know 
that the leguminous proteins are less digestible than 
those of animal origin, but we have little experience 
as to the application of this matter to infants, who 
may be quite incapable of utilizing this sort of food 
advantageously. 



CARROTS 179 

A few years ago, Ruhrah 1 advocated a similar employ- 
ment of the seeds of the Japanese soy-bean, a related 
vegetable, which has, however, the marked disad- 
vantage of containing about 15 per cent, of a vegetable 
oil. Ruhrah 1 makes up a gruel of about 10 per cent, 
strength, adding 5 per cent, of sugar, if a higher 
carbohydrate value is desired, for the soy-bean is 
decidedly lower in carbohydrates than our common 
kidney bean, containing barely 30 per cent. Attempts 
to popularize this food have so far met with little 
success; the fact is that the leguminous seeds are not 
very easily digested even by healthy adults, and pedia- 
trists are naturally somewhat cautious in giving such 
a food to young babies. The prejudice against the 
legumes may be unfounded, but evidence tending to 
abate it has not yet been furnished; it is therefore 
likely that further attempts in this direction will be 
few and far between until we can administer them 
along well-established physiological lines. 

Carrots. — Carrot-soup was so highly recommended 
for acute digestive disorders by Moro 4 and others, 
that Klotz 2 felt impelled to investigate this food 
thoroughly. He found that carrot-soup was, to be 
sure, only rarely rejected by the infant, but this was 
about all that could be said in its favor. The diges- 
tive trouble remained unaffected, and the protein 
absorption was very poor, as is probably the rule with 
the vegetable proteins. The really remarkable thing 
is that anybody should look for good results, in cases 
of indigestion, by feeding a woody vegetable like the 
carrot, rich in carbohydrates, but even in this respect 



180 INFANT FOODS OTHER THAN MILK 

not superior to a thoroughly cooked potato. In my 
opinion, endeavors of this kind are simply therapeutic 
aberrations. 

Hemp-soup. — I mention hemp-soup, made of hemp- 
seed, merely because it also has been proposed by good 
authorities, and has met the same fate as carrot-soup 
at the same hands (Klotz 3 ). We need not waste addi- 
tional space on this unpromising subject. 

Banana Meal. — Vipond is the author responsible 
for the recommendation of banana flour as an infant 
food. His suggestion presents one obvious disad- 
vantage in that banana flour is a rare market product, 
not in general demand, and therefore almost unob- 
tainable. Furthermore, Vipond's own reports furnish 
no evidence of any real superiority to the ordinary 
cereals. It is credited with being somewhat astringent, 
but this is rather a disadvantage in feeding normal 
infants, because they are already subject to constipa- 
tion. In diarrheal conditions, wheat flour and barley 
meal have proved themselves so satisfactory as intes- 
tinal astringents, which by the way are not usually 
indicated, that the necessity for other farinaceous 
foods is not clear. Banana meal is therefore, in all 
probability, an unnecessary addition to our dietetic 
armamentarium, and its recommendation is merely 
additional evidence of the general dissatisfaction with 
the results of artificial feeding. It represents one of the 
countless endeavors to find something that will agree 
with delicate or sick babies, whose real requirement 
is not this or that infant food but the human 
breast. 



WATER 181 

Fruits. — There is practically no literature on the 
subject of giving fruits and fruit-juices to babies; the 
entire matter seems to have been tabooed by nearly 
all pediatrists, and, as a general proposition, this 
attitude is probably correct, for even cooked fruits, 
with the cellulose separated, so far as this is possible, 
are rather unsuitable food during the first year. As 
to fruit-juices this is not quite so certain; they have 
a well-defined antiscorbutic action, of which we may 
often avail ourselves, in artificial feeding, especially 
if we give mixtures that are more or less throughly 
sterilized. I have made it a rule to give very small 
doses of orange-juice to babies who had to be raised 
on a diet that might possibly induce scurvy, and have 
seen no harm resulting therefrom. When scurvy has 
actually supervened, orange-juice is one of the best 
specifics for this disease; it is always given in quite 
a liberal quantity, and has never been found injurious 
in the least degree. Oranges and the related fruits 
of the genus citrus have the great advantage that 
they may be given raw; other fruits, such as apples 
and peaches, must first be cooked, and may not be so 
effectively antiscorbutic in that state, so that it is 
hardly worth while to suggest their juices as substitutes. 

Of other fruits I desire to mention only pineapples, 
the juice of which contains a proteolytic ferment. 
This fruit, that is its juice, might therefore be con- 
sidered when a proteolytic ferment is called for, but 
we have seen that this is rarely, if ever, the case. 

Water. — It is a constantly recurring question whether 
we should give an infant water in addition to that con- 



182 INFANT FOODS OTHER THAN MILK 

tained in its regular fluid diet. This question is usually 
answered affirmatively in an off-hand way, but seems 
to me to be entitled to careful consideration for the 
following reasons. In the first place, most of the 
formulas, as w T ell as the calculations that have been 
made in regard to breast-feeding, allow for an amount 
of fluid that satisfies the physiological requirements 
under ordinary circumstances; secondly, our present 
feeding methods already fill the infant stomach to 
its capacity, and that organ is allowed to be empty 
for only a short time, with the longer feeding interval, 
and not at all, according to the older methods; thus 
there is little room left for additional liquids. The 
third point is that there is no necessity for water beyond 
the physiological requirement, and an extra supply 
merely interferes with the normal water metabolism, 
causing an increased excretion of urine in the first 
instance, and increased perspiration and, in extreme 
cases, diarrhea if the kidneys prove insufficient. 

The problem therefore narrows itself down to this: 
additional water should be given when specially 
indicated; it only remains for us to point out the 
indications, and these are relatively simple. First 
comes hot weather; under this condition it is important 
that the baby should get rid of body heat, through 
evaporation from its skin surface, and this is managed 
by means of perspiration. The most effective means 
of promoting perspiration, when the surface of the body 
is overheated, is to give water; this should not, however, 
be done to excess, and usually 5 per cent, of the body 
weight; i. e., eight ounces for a ten-pound infant, 



WATER 183 

given in divided doses through the day, will he suffi- 
cient; it is best to give the water when the stomaeli 
is presumably nearly or quite empty, namely, about 
three hours after a meal. 

Similar physiological demands are made in the 
presence of fever, and the body temperature can be 
somewhat reduced by giving water freely. Here we 
may give larger quantities and more frequently, as 
the meals in severe febrile conditions are purposely 
made smaller and more easily digestible, by giving low 
fat ratios. When the fever is high we need not hesitate 
to give one-tenth of the body weight in water per day, 
which would amount to about four ounces every four 
hours for a baby weighing fifteen pounds. 

Of course, water should not be given to babies iced, 
but it need not be at blood heat; since our main pur- 
pose is to lower the temperature it may be given 
moderately cool, at the temperature of the room in 
fever, and at about 70° F. (21° C.) in hot summer 
weather. 



CHAPTER VII. 
ARTIFICIAL FEEDING. 

It would not be astonishing if the reader emerged 
from the perusal of the last three chapters in a state 
of mental confusion. More than a dozen methods 
of feeding have been presented, each with sponsors 
and detractors; none is adequate to the satisfactory 
nourishment of more than a bare majority of infants, 
many are adapted to merely temporary employment, 
many more are productive of at least as much harm 
as good. Unfortunately the confusion that is referred 
to gives an accurate picture of the present situation; 
a system of artificial feeding that really meets the 
requirements is still awaiting discovery; the question 
is, whether human ingenuity will ever prove itself 
equal to the task. In the mean time there remains 
only one proper and reliable way to feed a baby, and 
that is on breast-milk; artificial feeding is, so far, 
only a makeshift, a trial and vexation in a large per- 
centage of cases, and only tolerably satisfactory when 
most successful. 

In a large proportion of infants, however, artificial 
feeding is simply unavoidable; it remains for us to 
do the best we can with the imperfect means at our 
disposal. 



ARTIFICIAL FEEDING 185 

Based on the experience of twenty years with 
thousands of infants, my own preference is for the 
simple method of modification, that I learned from 
Jacobi, amended to fit the longer feeding interval that 
has been found best suited to the infant's digestion, and 
somewhat amplified by the addition of more formulas, 
so as to furnish a convenient table for ready refer- 
ence. I have given my table on a previous page (152), 
but regard it as merely adapted to my own purposes; 
anybody who understands and employs this method 
can readily draw up an equally good table for his own 
use. Jacobi's modification, as already stated, errs 
slightly on the side of safety; there is a little tendency 
to underfeed the infant, so that it gains in weight a 
trifle more slowly during the first six months than 
the standard tables call for; otherwise I have found 
it superior, in every respect, to top-milk feeding, which 
is advantageous only with such babies as digest cow- 
milk fat with unusual ease, but productive of harm to 
infants whose digestive powers are less efficient. I 
therefore always begin by diluting whole milk with 
the proper amount of barley water, adding either 
cane-sugar or milk-sugar, according to the financial 
resources of the family; we have seen that the absorb- 
ability of these two sugars differs but slightly, though 
the latter is, perhaps, slightly more laxative, and 
therefore preferable. 

We may regard a bottle-fed infant as thriving if it 
does not vomit, voids approximately normal stools, 
does not suffer from colic, and gains in weight. As to 
the last w T e must not expect the remarkably uniform 



186 ARTIFICIAL FEEDING 

and rapid increase that we are accustomed to see in 
successfully breast-fed infants; we should be satisfied 
if the weekly weighings invariably show some gain, 
even if the rate, in the successive weeks, shows con- 
siderable variation. Daily weighing is unnecessary 
for apparently healthy infants; the figures are sure to 
be somewhat irregular, since the bowels and bladder 
may be full on some days and empty on others, even 
if care is taken to choose the same hour for the daily 
weight-taking. This unavoidable irregularity amounts 
to two or three ounces (50 to 100 grams), much more 
than the normal daily gain in weight, and is therefore 
a confusing factor that it is wise to eliminate. Even 
semiweekly weighing is unnecessary, after the first 
two weeks, unless we have reason to doubt that the 
baby is making progress, in which case it may be 
desirable. Too frequent weighing, especially in bottle- 
fed infants, yields such fluctuating results as often 
to set the parents' nerves on edge, with the eventual 
risk of a similar reaction on the attending physician. 

A very important matter is not to be hasty in chang- 
ing the formula because of a temporary slowness in 
gaining weight, so long as the baby seems comfortable 
and is evidently assimilating its food. Bottle-fed 
babies may safely be allowed to lag behind slightly, 
provided their general condition is satisfactory; I 
cannot insist too strongly that most of the troubles 
that arise in the course of artificial feeding are due 
to overfeeding in the attempt to push up the weight. 

If the infant's weight is persistently stationary, or 
even declines slightly, for two weeks, everything else 



ARTIFICIAL FEEDING 187 

being normal, the best procedure is to pass on to the 
next higher formula, which may be clone without 
regard to the age column, which, as previously stated, 
is only a general guide; in many of these cases it is 
quite likely that the proteins as well as the fats 
are insufficient. If the baby still fails to gain, and the 
feces indicate that an increase of fats is likely to be 
tolerated, we may replace whole milk with a 24-ounce 
top-milk (5 per cent, fat), advancing, if necessary, to 
a 20-ounce top-milk (6 per cent, fat); it is very rarely 
that we shall be called upon to go beyond this ratio. 
By this time the baby will be at least six weeks old, 
when the fat-proportion resulting from the mixture 
last mentioned will not exceed 2.8 per cent., which 
is far below the 4 per cent, ratio allowed by Rotch's 
tables at that age. 

I do not necessarily pass on to the next formula 
at any fixed time, but let myself be guided by the 
infant's weight, increasing the amount of milk only 
if the gain is not satisfactory. With the conservatism 
in fat dosage that is a feature of this method, there 
is less danger of developing the fat type of rickets 
than when we give high fat and low proteins to 
babies who tolerate cow's milk easily, gain rapidly 
in weight, but do not acquire a proportionate growth 
of bone and muscle. The appearance of such infants 
is most deceptive when regarded with an uncritical 
eye, and they give a false impression of robustness that 
is quite unjustified. 

My table does not provide for giving whole milk, 
forty ounces per day, until the twelfth month, but many 



188 ARTIFICIAL FEEDING 

infants anticipate the schedule almost from the begin- 
ning and can take whole milk successfully a month or 
two earlier. 

Many, possibly the majority of physicians, still 
prefer to employ the top-milk percentage method, 
with its high fat ratios. There is no doubt that this 
plan has scored thousands of successes, and that such 
babies as tolerate it often thrive exceedingly well, 
especially in the second half of the first year. Some 
of these infants almost rival nurslings in weight and 
outward appearance, though the practised eye misses 
a certain rosiness of color and the experienced hand 
the rubber-like hardness of flesh that is usual even in 
second-rate breast-fed babies. 

If in spite of what has been said the reader has made 
up his mind to feed with top-milk from the first, I 
would urge him to take to heart the following words 
of caution. First, he should on no account give the 
frequent feedings, originally recommended, but employ 
the modified table (p. 139), which has been corrected for 
the four-hour interval; in this way one main source of 
trouble, namely, overloading, will be effectually guarded 
against. In the second place, he should make sure 
that his supply of stock milk is derived from Holstein 
or grade cows, and does not contain over 4 per cent, 
of fat; Rotch's method, as it is, touches the limit of 
safety, and the slightest step over the line is an invita- 
tion to disaster. Thirdly, he should watch the infant, 
and especially its evacuations, with particular care, 
reducing the fat ratio on the least suspicion of trouble. 
If these precautions are sedulously observed he will 



HOME MODIFICATION L89 

undoubtedly achieve a certain percentage of successes 
with this method, and also, in my opinion, develop 
an unwarranted feeling of security, which will receive 
a rude shock as soon as he encounters one of the many 
babies who take unkindly to this sort of feeding. 

If the practitioner chooses to avail himself of one 
of the milk-laboratories, now to be found in practically 
all of our larger cities, the preparation of the formulas 
is taken out of his hands, and those of the family, and 
the chief risk involved, is the possibility, already men- 
tioned, of the spoiling of the day's supply in transit. 
If, however, he prefers home modification, to which 
any intelligent mother or nurse can be trained, he must 
inculcate the following special precautions, aside from 
the one already mentioned, regarding the quality of 
the stock milk, which should be the best obtainable 
and low in fats. 

Home Modification. — The required apparatus includes 
an 8-ounce glass graduate, a glass funnel, a Chapin 
1-ounce dipper, a two-quart mixing pitcher, feeding- 
bottles, an ice-box, and a sterilizer. In addition there 
should be a plentiful supply of rubber nipples, cotton, 
and bottle-brushes. The bottles should be graduated 
and cylindrical, and fairly wide mouthed, to facilitate 
cleaning; the bottles with tubing attached, which defied 
all attempts at cleaning, have happily almost disap- 
peared from the market. The holes in the nipples 
should be sufficiently large to permit rapid dropping 
of the milk, but not free flow in a stream. When not 
in use the nipples should be kept in a solution of boric 
acid. Bottles should be washed immediately after feed- 



190 ARTIFICIAL FEEDING 

ing, with cold water, followed by a thorough scrubbing 
with hot soap-suds, using a bottle-brush, then kept 
filled with boric acid solution, and rinsed with pure 
water just before refilling. The nipples should also 
be scrubbed with hot soap-suds, and a clean tooth- 
brush immediately after feeding. 

The whole day's food should be prepared in the 
morning, according to the physician's formula, taking 
the precaution of dissolving the sugar in the hot water 
or cereal decoction, before gradually stirring in the 
milk. The result is then filled into the proper number 
of bottles, which are stoppered with cotton, placed in 
the ice-box, taken out one by one as required, warmed 
to near blood-heat, and last of all capped with a nipple. 

These regulations apply to all the home modifications 
of milk; the only difference is in the ingredients. As 
to the more difficult modes of milk modification, I 
have given the methods of preparation, one by one, in 
the previous chapters. Of course, the whole milk 
dilutions, consisting solely of plain milk, cereal water, 
and sugar, are the most simple of all to prepare; some 
of the more complicated mixtures, as albumin-milk, 
have to be demonstrated by the attending physician 
or a specially instructed nurse. 

Let us pass on to the digestive difficulties, en- 
countered in artificial feeding. 

Constipation. — Constipation is the bugbear of nearly 
all artificial methods of feeding, and its minor degrees 
are often almost unavoidable, being chiefly due to the 
poor absorption of fat, or the low percentage that has 
been necessitated by a regard for the infant's safety, 



CONSTIPATION 191 

at least during the earlier months. If the constipation 
is only moderate, with rather hard movements, instead 
of the normal semisolid evacuations, and the baby 
seems to suffer no harm or special discomfort, it is 
often the wisest plan, to leave well enough alone or 
substitute oatmeal for barley, but many infants do 
tolerably well, gaining fairly rapidly in weight, in spite 
of some torpidity of the bowels. If the constipation 
becomes troublesome, leading to occasional attacks 
of colic, or to straining at stool, our first step should 
be the same as recommended for failure to take on 
weight, namely, to pass on to the next higher formula; 
similarly, the giving of higher fat percentages should 
be resorted to cautiously, since the danger involved in 
high fat feeding, enormously outweighs the mischief 
caused by moderate constipation. 

The physician must ever bear in mind that artificial 
feeding places the infant in a dilemma. On the one 
hand the low fat diet, poorly assimilated at that, favors 
the development of rickets, and in any case interferes 
with the full muscular growth of the intestinal walls, 
so that a tendency to costiveness is unavoidable. On 
the other hand, &ny attempt to give cow-milk fat in 
the proportion in which fats are present in human milk 
involves one of the greatest possible risks to which 
an infant can be subjected. Confronted with this 
situation, we do well to be satisfied with a partial 
success and not aim at the attainment of perfect results. 

If the constipation is severe and causes discomfort, 
and we have pushed the feeding as far as is safe, the 
best plan, in my experience, is to substitute one of the 



192 ARTIFICIAL FEEDING 

dextrin-maltose mixtures for milk-sugar or cane-sugar. 
It is not that the malt is, in itself, especially laxative, 
but we have seen that it acts as a check on abnormal 
fermentation, such as is apt to occur when the bowels 
are costive. It must be remembered that the dis- 
comfort that attends constipation is due to fermentation 
and distention by its gaseous products, not to the mere 
presence of somewhat less fluid and more slowly moving 
intestinal contents. The hard feces of constipation 
become a feature only in the large intestine, whereas 
the fermentative processes begin much higher up. 
Many an infant may be relieved of the more distressing 
symptoms of constipation by giving malt; I may add 
that malt-feeding can be kept up throughout infancy 
if necessary, and that malt is no more likely to lead 
to rickets than either cane-sugar or milk-sugar. We 
shall go into the etiology of rickets more fully later; 
at this point it will suffice to say that it is in no way 
related to sugar metabolism. The danger of causing 
rickets, that is associated with Keller's original malt- 
soup mixture, lies in its low food value, especially in 
its exceedingly low protein and fat percentages; the 
babies who are fed on this compound too long are 
simply starved into rickets. The reader will under- 
stand, by what has gone before, that feeding on Keller's 
malt-soup, and substituting malt for milk-sugar in 
an ordinary formula, are two very different things, 
and intended for very different purposes. 

'While we may, in desperate cases, occasionally 
resort to glycerin suppositories or soap-suds enemas 
to relieve infant constipation, any regular resort to 



VOMITING 193 

such methods is an error so long as our dietetic resources 
have not been exhausted. Magnesium peroxid, in 
the form of milk of magnesia, is given extensively, 
in fact too often; I have seen as many failures as 
successes with this salt, and do not agree with Donath, 
who says that a daily dose of 1 gram of magnesium 
peroxid may be relied on to be effective, without 
diarrhea and without habituation. A still greater 
blunder is the resort to the ordinary purgatives, 
especially rhubarb, with its constipating after-effect. 
Intractable constipation in an infant is a classical 
symptom of rickets, and if dietetic measures fail, we 
may generally rest assured that a rachitic condition 
is already established. The best proof of this relation- 
ship is furnished by the experience that a vigorous 
antirachitic course of treatment is more effective, in 
these cases of chronic constipation, than any merely 
symptomatic measures. 

Colic. — Intestinal colic is usually a symptom of 
some severe intestinal disturbance, but sometimes, 
as already indicated, may attend mere constipation; 
in the latter event it is only occasional, and does not 
call for any special method of treatment. 

Vomiting. — The young infant vomits easily and 
without effort; surplus food readily overflows through 
the feebly closed cardiac orifice of the stomach. Partial 
vomiting, i. e., the regurgitation of only a small portion 
of the ingesta, is popularly designated as "spitting." 
Spitting is a frequent and annoying symptom in arti- 
ficial feeding, but has become far less common since 
the introduction of the four-hour feeding interval; it is 
13 



194 ARTIFICIAL FEEDING 

simply the result of overloading the stomach, and an 
almost unavoidable consequence of allowing too short 
a pause between feedings. The treatment of this 
condition is indicated by the above account of its 
etiology. 

Apart from mere spitting, vomiting is always a 
symptom of some seriousness in a bottle-fed child; 
if it is persistent and uncontrollable, beginning about 
tw T o weeks after birth, it is a characteristic feature of 
the affections known as pyloric stenosis and pyloro- 
spasm. Excluding these affections it is a sign that 
cow's milk, at least as given, does not agree with 
the infant; the case is one of digestive disturbance 
and must be treated accordingly, unless the vomiting 
occurs at long intervals. In many cases vomiting may 
be checked by going back one formula, or abandoning 
top-milk, if that has been given, in favor of properly 
diluted whole milk. 

Occasional vomiting is one of the common and 
unpleasant concomitants of top-milk feeding; and 
has been one of the chief factors in impairing the 
credit of this method; as the top-milk percentage 
system, as usually carried out, combines both the evils 
of too frequent feeding and too high fat ratios, it is 
easily understood why vomiting so often is associated 
with this mode of raising infants; with careful avoid- 
ance of the two mentioned errors, this distressing 
symptom will nearly always be controllable. 

Diarrhea. — In breast-fed infants, two, three, or even 
more green and loose evacuations, although they may 
contain whitish particles of undigested fat, are of no 



DIARRHEA 105 

very great significance; in bottle-fed infants, on the 
other hand, they should always be regarded as danger 
signals. Even a mild attack of diarrhea is usually 
a symptom of fat-dyspepsia which, taken in time, 
may often be promptly checked. I treat such cases 
by giving a single purgative dose of castor oil, cutting 
off all food for twenty-four hours, and then starting 
in with a very low fat formula, often using skim milk 
or buttermilk to begin with. These attacks of diarrhea 
in otherwise thriving infants are usually due to attempts 
to give high fat mixtures, and therefore specially 
common in top-milk feeding. It must not, however, 
be forgotten that the presence of fever, from any 
cause, is very apt to be attended with intolerance of 
fats, without any demonstrable error in the direction 
of overfeeding; in these cases it is also w T ell to go over 
to a low fat regimen until the febrile disturbance has 
abated. 

Should these slight diarrheal attacks tend to recur, 
or should the infant have the normal number of stools, 
namely, one or two daily, but of diarrheal character, 
the wisest plan is to proceed at once to malt feeding, 
substituting a dextrin-maltose mixture for the added 
sugar. We have seen that malt decidedly favors fat 
absorption, and it is remarkable to see how rapidly 
the tendency to diarrhea often ceases on a diet contain- 
ing a low percentage of fat and sweetened with malt. 

If the abnormal stools, just described, are disre- 
garded one of two events is likely to take place: the 
baby either goes over into the condition that the 
Germans call Milchnahrschaden (milk-atrophy), to be 



196 ARTIFICIAL FEEDING 

discussed in detail later, or develops true fat-diarrhea, 
already referred to as a serious symptom. I have 
before described the yellow and oily fat stools, nearly 
normal in color, very fluid, and leaving greasy spots 
on linen and paper. In the light of our present know- 
ledge the development of fat-diarrhea is nearly inex- 
cusable, because we have become fully acquainted with 
its origin; it can occur only if we ignore the warnings 
given by the less grave anomalies of the feces, and 
persist in giving fats, in the ratio of 3 or 4 per cent., 
merely because certain authorities still recommend this 
mode of feeding as a perfectly safe routine diet. 

Soap Stools. — These have already been described; 
they are often an almost unavoidable accompaniment 
of bottle-feeding, and are associated with more or 
less constipation. Soap stools are to be regarded by 
the attendant in very much the same way as the 
diarrheal evacuations previously mentioned; they rep- 
resent a milder type of fat-indigestion, unattended by 
fermentation or irritation, because here the calcium 
soaps play a more prominent role than the free fatty 
acids, which are the prime factors in diarrhea. The 
seriousness of the soap stools is therefore perhaps less 
imminent, but they may also pass on, rather suddenly, 
to fat-diarrhea, so that we should do our best to get 
rid of them by readjusting the diet. In accordance 
with the similar etiology the same treatment as for 
diarrhea applies to soap stools; by going back to a 
moderately low fat mixture with malt we shall succeed 
in securing more nearly normal evacuations in a vast 
majority of these cases. 



SOAP STOOLS 197 

Viewing the difficulties of artificial feeding in their 
entirety, two clinical landmarks stand out prominently. 
In the first place we observe that the feces are a better 
guide than even the body weight in gauging the success 
or failure of any method of artificial feeding. We 
may sometimes disregard the baby-scales for a week 
or two, but we cannot, with safety, ignore the condition 
of the' bowel-movements for a single day. Whoever 
wishes to succeed in artificial feeding must comprehend 
the terminal stage of his milk-mixtures as thoroughly 
as he understands their original preparation. In the 
second place we find that there is only one reliable 
remedy when every attempt at formula feeding seems 
to go wrong, and that is breast-milk. It is true that, 
under many circumstances, especially in this country, 
the remedy is practically unobtainable; this does not 
lessen its value, and the lack of it very often puts the 
infant in the greatest jeopardy. 

There is a certain percentage of infants who cannot 
obtain breast-milk for various reasons, and must there- 
fore be nourished artificially, who keep the parents 
and medical attendant in a constant state of anxiety, 
because they will not thrive on any form of milk- 
modification. During the first three to six months 
they gain only fitfully, often only to lose their hardly 
gotten gains, because they do not tolerate a mixture 
that is sufficiently high in food value to more than 
just keep them alive; of course, their very lives are 
continually in the balance, and the difficulties of the 
physician can be readily understood. There is, how- 
ever, one encouraging side to the situation; at some 



198 ARTIFICIAL FEEDING 

ill-defined period, sometimes in the third month, 
sometimes not until later, the baby suddenly begins 
to absorb and assimilate its food, and the last formula, 
as well as the last consultant, gets the credit of what 
is largely a coincidence. Some of these cases, unfor- 
tunately, fall victims to their food-intolerance or to 
some intercurrent affection that would be overcome by 
a normal infant. The mortality among infants, from 
infectious and other febrile diseases, depends to an 
enormous extent on whether they have been breast- 
fed, successfully bottle-fed, or belong to the group 
of feeding-failures. These last babies represent an 
almost irreducible minimum, of whom a certain ill- 
defined percentage has barely an equal chance of 
survival and for whom the most ingenious plan of 
artificial feeding will remain a physiological misfit. 

Feeding During the Second Half-year. — During the 
first half-year, as we have seen, it is a good rule to 
allow all errors in feeding to be on the side of safety 
and to permit a slight degree of underfeeding rather 
than take any risks. There is no occasion for worry 
if the baby is a pound or two underweight, provided 
it shows no signs of actual illness; Birk 4 has shown 
that the body length suffers impairment only in very 
severe malnutrition, but that a small deficiency in 
weight, in the earlier months, may easily be made 
up during the second half-year. After the age of about 
six months many infants, who previously had diffi- 
culty in utilizing cow's milk begin to tolerate and 
assimilate that food quite well; if the weight at that 
age is not quite satisfactory, and the baby's condition 



MIXED FEEDING 1<M) 

and especially the stools, make it evident that a richer 
food is desirable, we may at once proceed to run up 
the fats. 

At six months of age my table calls for a mixture 
consisting about two-thirds of milk and one-third of 
barley water, yielding a protein percentage of 2.2 
and a fat percentage of 2.6. If we take the allotted 
26 ounces of milk from the top of the bottle, rejecting 
the lowest 6 ounces, we obtain a 4.8 per cent, milk 
which will, on dilution, give a fat ratio of 3.2 per cent., 
not excessively high for that age, but giving a daily 
addition of 1.4 ounce of fat, 70 calories per day, and 
about 10 calories per kilogram of weight. This increase 
will generally suffice to convert a slow gain into a rapid 
one without incurring much risk. As already observed, 
it is during the second half-year that the top-milk 
percentage method has scored its great triumphs; 
some of its features may very well be borrowed at 
this period, with profit to the infant, and no hazard 
of consequence, if we are careful to continue close 
observation in each individual case. 



MIXED FEEDING. 

When the two-hour feeding interval reigned supreme, 
it often happened that a mother could not supply 
a sufficient quantity of milk with such frequency; 
this often led to what has been aptly called mixed 
feeding, the scanty ration of mother's milk being 
eked out with a suitable cow-milk mixture. Since the 
adoption of the four-hour interval this trouble has 



200 ARTIFICIAL FEEDING 

become less common, but is still by no means rare. 
All authorities agree that mixed feeding, while inferior 
to breast-feeding by itself, has many advantages 
over exclusively artificial alimentation. The infant 
obtains, at any rate, a certain quantity of easily diges- 
tible food, so that the supplementary bottle-feeding 
may be given with a very low fat percentage without 
incurring the risk of fat starvation, the mother furnish- 
ing a fairly adequate amount of this milk ingredient. 

Voix discusses the three possible methods of apply- 
ing mixed feeding: (1) we may alternate between the 
breast and the bottle; (2) we may give the bottle in 
the daytime and the breast at night, or vice versa; 

(3) we may supplement each nursing with a small 
quantity of the artificial food. He prefers the third 
method, which is often easily carried out, by adhering 
to the four-hour feeding interval. 

Perier looks at the question from the sociological 
point of view, and gives four reasons for mixed feeding : 
(1) if the breast-milk is insufficient; (2) if the mother 
has to earn her living, in which case the bottle will 
have to be given once or twice during the middle of 
the day; (3) in raising twins, for obvious reasons; 

(4) as a transition to weaning. The third of these 
reasons is also dwelt on by Eustache ; it will be recalled 
that we cannot, as a rule, reckon on a woman's yielding 
more than one or one and a half liters (quarts) of milk 
per day (Thiemich 1 ); this quantity is pretty certain 
to be insufficient for the nursing of twins, after the 
first few months, so that supplementary feeding is 
quite likely to be called for as the twins grow older. 



THE FEEDING OF PREMATURE INFANTS 20] 

Mixed feeding has been most assiduously studied in 
France, and is inculcated at the French milk-stations 
whenever possible. There is surprisingly little litera- 
ture on the subjeet in other languages, and it is evi- 
dent that this method has not received the universal 
attention that it deserves. The physicians of other 
nationalities are too easily discouraged and go over to 
exclusive bottle-feeding much too readily. 

In my own experience I have had the best results 
with Voix's first method. It is very often possible for 
the mother to nurse her baby three times a day, namely, 
at G a.m. and 2 and 10 p.m.; this will necessitate only 
two artificial feedings, at 10 a.m. and p.m. respectively. 
This plan is specially applicable to those cases where 
the mother's mammary gland is of the virginal type, 
and secretes an insufficient quantity of milk the quality 
of which is quite satisfactory. In these cases I have 
obtained a number of excellent results, lasting for a 
number of months, and tiding the infants nicely over 
the critical early period. 

THE FEEDING OF PREMATURE INFANTS. 

On this subject there is a considerable amount of 
recent literature, from which we may draw freely. Xo 
infants are in more urgent need of breast-feeding than 
such as are born before the full term; yet these very 
babies are most apt to be deprived of their natural 
food. Several reasons combine to produce this unfor- 
tunate state of affairs. In the first place the mother's 
breasts are not supposed to furnish milk at seven and 



202 ARTIFICIAL FEEDING 

a half or eight months, and, as a matter of fact, usually 
fail to do so; in the second place, the premature infant's 
power of suction is feeble, so that the most potent 
factor in promoting the free flow of milk, namely, the 
drawing of a vigorous baby, is lacking. In exceptional 
cases it is possible to obtain the milk of another woman 
for the premature infant; in this happy event our 
chance of raising it successfully is immeasurably im- 
proved. As a rule, however, we are forced to resort 
to artificial feeding from the outset, and the difficulties 
involved in this procedure are among the greatest that 
fall within the province of the pediatrist. 

Infants weighing over 2 kilograms (4.5 pounds) 
at birth run only the risks proportionate to their 
backward development; sometimes their mothers are 
able to nurse them, in other cases artificial feeding is 
finally successful, so that the mortality is not so very 
much larger than in babies of the normal weight of 
three to three and a half kilos (6.5 to 7.5 pounds); 
it is the babies under the 2 kilogram limit that here 
specially concern us. 

The caloric requirements of premature infants are 
relatively very great, because of the proportionally 
large body surface, and consequent excessive radiation 
of heat. Unless we supply artificial warmth we cannot 
raise these babies at all; they use up all their available 
energy in keeping up the body temperature, but do 
not even succeed well in this; their temperature falls 
below normal, and they soon die of inanition. Birk 5 
is undoubtedly mistaken when he puts the energy- 
quotient of these premature infants on a level with 



THE FEEDING OF PREMATURE INFANTS 203 

that of full-term babies; Samelson 1 sets it a1 115 to 
150 calories per kilo, J. II. Hess at 100 to L30 for babies 

weighing over 3.5 pounds, 115 to 170 for still smaller 
infants. It is evident that the low diet that is usually 
given to full-term infants during the earliest weeks of 
life will not suffice for these tiny morsels of humanity; 
on the other hand, the dangers of overfeeding them 
are aggravated by the poor development of their diges- 
tive organs. Oppenheimer advises us to go ahead 
boldly, starting with at least 90 calories per kilo daily, 
and advancing to 120 calories if the smaller amount 
has been well tolerated. Morse 2 and J. H. Hess agree 
in saying that the infant will not grow on less than 
120 to 140 calories, the latter figure being admittedly 
on the absolute danger line. We have seen that feed- 
ing so high as this is unsafe even for fully developed 
babies when several months of age; it is palpably 
hazardous under the conditions here being considered, 
as has been admitted, and even insisted on, by Cramer 2 
and Samelson. 1 

Our dilemma is only too apparent. Ladd 5 and 
Morse 3 report poor results; a gain of more than two 
ounces per week is regarded as uncommonly good; 
it usually averages lower for a number of weeks, even 
in cases that finally come out successfully. Birk 5 
considers buttermilk superior to whole milk, because 
the digestion of fat is specially poor in these infants; 
Litzenberg urges the four-hour interval for premature 
babies also. It is difficult to see how the last two 
recommendations can be made compatible with the 
high caloric values that are usually demanded; to 



204 ARTIFICIAL FEEDING 

my mind these propositions involve a mathematical 
impossibility. 

Personally, I do not even attempt to feed up to 
the high caloric standards referred to above; neverthe- 
less, I feel that I am trespassing over the danger-line 
in every case. To babies weighing over 1500 grams 
(3.5 pounds) I give my third formula, in 1.5-ounce 
portions, every three hours, day and night; the caloric 
total is about 140, say 70 to 90 per kilo, and at that 
I am aware that I am counting on a power of assimila- 
tion rather above the average. Still smaller infants 
get one-ounce portions of the same mixture at the 
same intervals, totalling about 100 calories per day, 
and about the same per kilo, as for the larger babies. 
Here the chances are poor, at best. Millon finds 
that only 36 per cent., of the babies under 1500 grams, 
survive; Ladd 5 gives the still lower proportion of 28 
per cent. From 1500 to 2000 grams (3.5 to 4.5 pounds), 
the outlook is considerably better, the respective 
figures of these two authors being 75 and 56 per cent. 
The limit of viability may be set at 1200 grams (2 
pounds and 10 ounces), though we may sometimes 
succeed in saving the life of a still smaller infant. 

The conservation of the premature infant's body 
heat, by means of a warm room and warm water 
bottles, is of course an indispensable requirement 
if we are to be at all successful. The electric pad, 
if skilfully managed, so as not to be overheated, is 
often a very valuable aid. The incubator, once so 
universally popular, is gradually falling into disfavor; 
it calls for special training in its use and an immense 



THE FEEDING OF PRE MATURE INFANTS 205 

amount of supervision, yet remains a rather dangerous 
apparatus in spite of the best attention and care. In 
a manual solely devoted to the feeding of infants 
there is no place for lengthy discussion of the merits 
and demerits of the incubator; it will suffice to point 
out the significant circumstance that many leading 
clinics, such as Langstein's, which formerly employed 
the incubator, have recently given it up (Rott). 



CHAPTER VIII. 

DISORDERS OF DIGESTION. 

The disorders of the digestion, in infants, may be 
divided according to their etiology into three groups: 
I. Physical disorders. 
II. Alimentary disorders. 
III. Infectious disorders. 
We shall begin with a consideration of such digestive 
disorders as have a purely physical basis; they agree 
in presenting a normal condition of the gastro-intestinal 
mucous membrane, and in this respect differ radically 
from the others. They are variously either functional 
or organic, and present characteristic clinical pictures 
that separate them sharply from the second and third 
groups, whereas among themselves the differential 
diagnosis may often be quite difficult. 

PHYSICAL DISORDERS OF DIGESTION. 

Pyloric Stenosis. — Congenital hypertrophic pyloric 
stenosis was first described by Beardsley, but his 
account was soon forgotten. Its symptomatology was 
accurately described by Williamson, but this paper 
also secured little attention. Hirschsprung was the 
first one to popularize a knowledge of this affection, 



PYLORIC STENOSIS 207 

and since his time some hundreds of cases have been 
reported, chiefly within the last twelve years. 

Pyloric stenosis presents a definite anatomical lesion, 
of which I 2 gave one of the first detailed descriptions 
in 1905. The essential feature is an enormous hyper- 
trophy of the muscular coats of the pyloric end of the 
stomach to fully four times the normal thickness; 
the enlarged pylorus presents a sausage-shaped mass, 
projecting into the lumen of the duodenum, its own 
orifice being narrowed to the diameter of from 2 to 
3 mm., and its walls being of almost cartilaginous 
hardness. In uncomplicated cases the mucous mem- 
brane of the organ is absolutely normal. 

Symptoms. — The symptomatology is characteristic of 
obstruction at the lower gastric orifice. There is vomit- 
ing of practically all ingested food, at varying inter- 
vals after meals; either constipation, or fairly frequent 
small green and mucoid evacuations, of the type known 
and described as hunger stools. The child presents 
the typical picture of progressive emaciation, but no 
fever or other symptom that would point to an infec- 
tious or toxic process. 

On examination we find the physical signs of dila- 
tation of the stomach, often with visible peristalsis. 
Sometimes, but by no means always, we find a palpable 
tumor in the right epigastric region; the deep situa- 
tion of the pylorus often interferes with its successful 
palpation. 

The first symptoms of this affection appear at 
the age of two or three weeks, when the infant, 
hitherto apparently perfectly well, begins to vomit, 



208 DISORDERS OF DIGESTION 

though there is no evidence of any error in the 
diet. The majority of these babies are indeed breast- 
fed, but this is true of babies in general; it merely 
shows the absence of a dietetic cause. The vomiting 
soon becomes persistent, and presently very intense 
and forcible, not by any means resembling regurgi- 
tation or " spitting." From this time onward the infant • 
begins to lose in weight, and from having been in a 
flourishing condition at the age of two or three weeks, 
rapidly becomes reduced almost to a skeleton. 

Unless relieved by treatment the disease continues 
unchanged, and the infant dies of inanition before 
the end of the third month. The postmortem findings 
have already been described. 

Before discussing the treatment of pyloric stenosis 
it will be best to give a brief description of a clinically 
similar affection, easily confused with it, namely : 

Pylorospasm. — Pfaundler 2 was the first to give a 
good account of pylorospasm, which was, for some 
years, confused with organic pyloric stenosis. For 
some years writers on these subjects were divided into 
two camps, consisting respectively of those who 
regarded the clinical picture as due to organic obstruc- 
tion and those who looked on it as a muscular spasm, 
with perhaps a secondary development of hypertrophy. 
Ibrahim 3 tried to compromise between these parties 
by recording his belief that the hypertrophy was 
the result of the spasms and might disappear spon- 
taneously on their cessation, thus accounting for the 
undoubted cases of recovery from this group of symp- 
toms. I must mention that Pfaundler 2 thought that 



PYLOROSPASM 209 

the enormously enlarged pylorus represented a post- 
mortem contracture, since it was evident that these 
cases could otherwise be curable only on the basis of 
an hypothesis such as was later supplied by Ibrahim. 3 
This is disproved by noting the great enlargement of 
the pyloric end of the stomach in every direction as 
well as in total bulk; these large masses of muscle 
cannot be the product of a mere postmortal spasm. 

Koplik, 3 a few years later, took the standpoint that 
has ever since been generally accepted, namely, that 
there are two forms of pyloric obstruction in infants: 
An anatomical stenosis, due to hypertrophy of the 
muscular wall, and a functional occlusion, due to 
muscular spasm. Whereas knowledge of the former 
condition has practically stood still since the publica- 
tion of my paper, the contributions to the sub- 
ject of pylorospasm have become plentiful and 
illuminating. 

Symptoms. — The symptomatology of pylorospasm 
closely resembles that of hypertrophic stenosis; we 
have the same onset after two or three weeks, the 
same violent rejection of some but usually not all food, 
more or less constipation, and sometimes, but not so 
often, hunger stools and a variable degree of emacia- 
tion. Even visible peristalsis and a palpable tumor 
have been noted by some observers, from Koplik 3 
onward, though the tumor seems to be rather smaller. 
It will be seen that the only noteworthy distinction 
is that in pylorospasm the symptoms are apt to be 
less severe, because the obstruction is only partial or 
intermittent. 
14 



210 DISORDERS OF DIGESTION 

In the presence of severe symptoms the differential 
diagnosis between hypertrophic stenosis and spasm 
is almost impossible; this leads to the suspicion that 
intermediate conditions may exist. Holt 5 is convinced 
that spasm is always present in marked stenosis, thus 
accounting for the sudden onset of the symptoms, as 
well as the diagnostic difficulties; he regards persistent 
spasm as indicative of organic obstruction, and 
doubts if it is ever purely functional. Ibrahim's 
first conjecture may be correct after all and the 
two affections may be not distantly related; this 
opinion of course, for the present, remains a mere 
hypothesis. 

Certain accessory phenomena are quite constant in 
pylorospasm. In the first place there is an abundance 
of highly acid gastric secretion, and the spasm increases 
as the meals are made more ample. This appears to 
be one of the reasons why the disease does not show 
itself in the first two weeks after birth. We know 
that the supply of breast-milk is at first rather scanty, 
as is the secretion of gastric juice at that period; in 
artificial feeding we purposely give little food during 
the first fortnight, so that conditions in this respect 
are similar. 

Diagnosis. — The diagnosis of pyloric obstruction, 
without specifying the cause, is easy enough when 
all the signs are present, but may be quite difficult 
when vomiting is the only symptom. Persistent 
vomiting in spite of careful regulation of the diet is 
very characteristic; in other digestive disturbances, 
vomiting is less obstinate and especially less violent, 



PYLORIC STENOSIS AND PYLOROSPASM 211 

responding, at least to a certain extent, to carefully 
regulated feeding. Furthermore, severe vomiting 
from digestive derangement is always associated with 
more or less diarrhea, with evidence of indigestion in 
the feces. Vomiting, due to obstruction farther down, 
in the intestine, is not always easy to differentiate, 
but is likely to be characterized by the bringing up 
of bile and intestinal contents of an alkaline reaction, 
which is manifestly impossible if the pylorus is occluded. 
Finally, the duodenal tube is very helpful when we 
have mastered its technique; if it passes the lower 
gastric orifice readily we have of course no severe 
pyloric obstruction to deal with. 

As to the diagnosis between hypertrophic stenosis 
and pylorospasm, the severe cases of the latter behave 
so much like the former that the test of treatment 
is often our only resource. Even this test is probably 
untrustworthy, for it is extremely likely that typical 
stenosis has been cured by purely medical treatment 
(Holt 5 ). Miller and Wilcox give a low acidity of 
the stomach contents and abundant secretion of 
mucin as characteristics of the former; the acidity 
test is certainly unreliable, as we may have a highly 
acid vomitus with hypertrophy; the secretion of 
mucin, in this condition, may also be quite moderate, 
for, at least in the case I 2 reported, the mucous mem- 
brane was absolutely normal, without any sign of con- 
gestion, so that its secretion could hardly have been 
affected. Koplik 3 thinks that very intense vomiting 
and a palpable tumor should incline us to diagnos- 
ticate hypertrophy, but his own experiences show 



212 DISORDERS OF DIGESTION 

that these tests are not infallible. It is just as well 
to admit that in many cases the two affections are 
clinically undistinguishable. 

Treatment. — As to treatment, let us begin with that 
of pylorospasm. Heubner's 2 procedure is probably 
the best, and is generally followed, though often with 
certain modifications. He urges feeding at four-hour 
intervals, giving less than the normal number of 
ounces in bottle-feeding, and materially shortening 
the time of nursing in breast-feeding. Since Feer 1 has 
shown that the infant obtains most of its food in the 
first few minutes after being put to the breast, I limit 
the time of nursing to three minutes. Heubner 2 as well 
as Miller and Wilcox urge us to increase the amount 
of food very cautiously, even after the vomiting has 
been apparently brought under control. Morse 8 
differs from these authors in recommending frequent 
small meals; he agrees with them in giving low fat 
percentages when artificial feeding is necessary. 
Nearly all authors recommend the use of alkalies; 
they must be given in moderation, as they tend to 
retard the gastric digestion if used to excess; the 
alkalies do not only neutralize hydrochloric acid, but, 
in a measure, counterbalance this action by favoring 
its secretion, so that their net utility is somewhat 
doubtful. They are not needed in breast-feeding, 
and in bottle-feeding I prefer to comminute the casein 
coagula by using barley water. Hess 4 makes the useful 
suggestion to feed obstinate cases through the duodenal 
tube; of course, this procedure is specially difficult 
in these very cases, but the idea has been followed 



PYLORIC STENOSIS AND PYLOROSPASM 213 

up and is theoretically perfectly sound; the mere 
passage of the tube is of a certain curative value. 

Ruhrah 2 notes the three following essentials in the 
treatment of pylorospasm : (1) feeding with breast- 
milk; (2) the administration of atropine in doses of 
0.03 mg. ; (3) in certain cases, the employment of 
codeine, beginning with 0.1 mg. and increasing this, 
when tolerated. We may note that Holt 5 is skeptical 
as to the value of any drugs in this affection. 

I have found, with Ibrahim, 4 that the four-hour 
interval is rather long, considering the very small 
meals which we are obliged to give; he feeds every 
hour or two, and I employ the latter interval myself, 
especially with breast-feeding; with artificial feeding, 
we must be more cautious, as it is absolutely necessary 
for the stomach to be empty between meals; low fat 
percentages aid us greatly toward this end, so that 
we can feed small meals to these babies, at any rate 
every three hours. 

All authorities agree that the infant must be kept 
very quiet after meals; warm compresses, or a very 
lightly filled hot-water bag, applied to the epigastrium, 
tend to check vomiting. Lavage is often recommended, 
but seems irrational; it appears to me that we are 
chiefly interested in keeping the food in the stomach, 
which is only too ready too empty itself. 

The above treatment is also in order, if true hyper- 
trophy is suspected; we should give it at least a week 
or two of trial, for some apparently unquestionable 
cases of hypertrophic obstruction have been relieved 
in this way; we have seen that the diagnosis is often 



214 DISORDERS OF DIGESTION 

very uncertain, so that the treatment with special 
feeding should always be tried before resorting to 
more radical measures. Our only other recourse 
is a severe operation, which has a high mortality at 
this age, especially as the infant usually comes to the 
operating table in very bad condition. The earnest 
solicitations of the surgeons should not induce us to 
be hasty in advising operation, for not so very rarely 
the autopsy has shown that there was no pyloric 
hypertrophy present, but that the severe symptoms 
were due solely to spasm. 

Megacolon. — Megacolon, hypertrophic dilatation of 
the colon, or Hirschsprung's disease, as it is variously 
called, was first described by the author just named. 2 
The second name gives a good description of the 
anatomical findings. The disease — or malformation — 
has many points of analogy to pyloric stenosis, though 
the symptoms are naturally very different. The lesion 
is either congenital, or acquired very soon after birth. 

Symptoms. — Meteorism and intense constipation are 
early symptoms, but meconium or decomposed feces 
do finally pass, so that a total obstruction in the 
intestine may be excluded. Vomiting is sometimes 
a prominent symptom, in other cases absent, as is 
usual with colonic coprostasis. The disease runs a 
very varying course, according to its severity; the 
worst cases die in the first or second year, from entero- 
genous toxemia or perforating ulcer of the colon, the 
milder ones may attain adult life. The most character- 
istic feature is the presence of large and externally 
visible coils of intestine, without anything to indicate 



MEGACOLON 215 

actual obstruction; next comes obstinate constipation, 
alternating with the evacuation of enormous masses 
of highly fetid fecal matter. 

Etiology. — The authorities are not agreed on the 
etiology of megacolon. Hirschsprung 2 regarded it as 
a malformation, whereas Marfan 1 considers it a true 
partial obstruction, due to kinking of the sigmoid 
flexure; Ibrahim 5 thinks that either cause may operate 
in different cases, but that Marfan's explanation 
probably applies to the majority. 

Treatment. — There is no dietetic treatment for 
megacolon. The milder cases may be treated by 
palliative methods, among which enemas are occasion- 
ally useful; in the severe forms the only possible 
treatment consists in resection of the colon, which has 
rarely been successful, and is apt to prove directly 
fatal. 

Other Spasms. — In a recent publication, Hess 5 
dwells at considerable length on pharyngospasm and 
cardiospasm in infants, which he sometimes finds 
associated with pylorospasm, sometimes with general 
spasmophilia. These spasms in the upper digestive tract 
are not very common, and the existence of true pharyn- 
gospasm is in need of further demonstration. The 
cardiac orifice of the stomach is, as already observed, 
more relaxed in infancy than in later life, as is shown 
by the great ease with which the stomach-tube is 
passed at an early age, and by the facility with which 
vomiting takes place. This condition is partly in 
relation to the normally low acidity of the gastric 
contents in infancy; we know that a high total acidity 



216 DISORDERS OF DIGESTION 

and a high percentage of free hydrochloric acid are 
important factors in keeping the orifices of the stomach 
tightly closed. A more important reason, however, is 
afforded by the relatively feeble development of the 
muscular coat of the baby's digestive canal. 

Singultus. — The mechanism of singultus or hiccough 
is not perfectly clear; it consists of a spasm of the dia- 
phragm, caused by a reflex through the phrenic nerve, 
which may be started by the most varied sources of 
irritation. Free hydrochloric acid in the stomach seems 
to be one cause; mere overloading of the stomach is 
often a factor; in many cases it is due to peritoneal 
irritation, in others no exciting cause can be elicited; 
Hess 5 says that it is often associated with pyloro- 
spasm. 

Treatment. — The treatment of cases, due to faulty 
feeding, consists in removing the cause; by giving low 
fat percentages, we diminish the tendency to hyper- 
acidity and spasm, and by giving smaller and less 
frequent meals, we avoid the factor of overloading. 

Rumination. — At first sight we might suppose 
rumination to be a phase of vomiting, but it actually 
is more closely allied to singultus. We can easily 
understand that hiccough, in an infant, will bring up 
a portion of the stomach contents, which may there- 
upon be again swallowed. Here, too, a connection 
with pylorospasm seems possible .or even probable, 
but Lust 3 is not satisfied with this explanation, and 
thinks that rumination is more apt to be the expression 
of a general neurosis, as it is known to be in later life. 
This point of view, though by no means well established, 



DIGESTIVE NEUROSES 217 

is yet of interest, as linking this condition with the fol- 
lowing class of digestive disorders. Briining observed 
rumination in cases of rickets and spasmophilia, and 
obtained a cure in connection or coincidence with 
antirachitic treatment. 

Digestive Neuroses. — The literature on the digestive 
neuroses of infancy is scanty, partly because the study 
of the nerve functions, at this period of life, is beset 
with special difficulties; furthermore, recent observers 
have become cautious, since in the past an excessive 
eagerness to assume a neurotic basis for serious organic 
disturbances has led to great errors in theory and 
practice. Of this tendency I need give but one instance, 
by referring to the role that teething was formerly 
believed to play in causing the most various and serious 
disorders; the nervous irritation produced by the 
physiological act of dentition was held responsible 
for a long list of lesions and symptoms, which we have 
learned to account for on an entirely different basis, 
in no relation whatever to the dental apparatus. 
Very few physicians of standing will today attribute 
the most serious digestive derangements, attended 
with vomiting, diarrhea, and fever, to the eruption of 
the teeth; yet a previous generation was convinced 
that the occurrence at the same period of the distur- 
bances due to weaning and the process of dentition 
was not a mere coincidence, but that the former were 
largely due to the latter. 

More scientific feeding methods have enabled us 
to prevent digestive disorders during the second half 
of the first year, so that the role of teething, as an 



218 DISORDERS OF DIGESTION 

etiological factor in organic disease, has been pretty 
well eliminated; on the other hand the nervous reac- 
tion caused thereby is not always trifling, especially 
in infants belonging to neurotic families; the fretf ill- 
ness, irritability, and restlessness of many teething 
infants whose alimentary tract is functionating quite 
normally is sometimes so obvious that it cannot be 
dismissed as an illusion. 

Some years ago Northrup reported a series of 
interesting cases, in infants of the age of four or five 
months, in whom constant exposure to nervous excite- 
ment through noise, jolting, playing, and showing 
off to visitors had caused rejection of food, gradual 
atrophy, loss of sleep, and the development of a 
neurotic habitus that was unmistakable; a prompt 
cure followed the adoption of a strictly restful mode 
of life. Such cases cannot be very rare, and it is 
astonishing that many more have not been reported. 
I am convinced that much of the vomiting and 
regurgitation that we see in otherwise healthy infants 
is caused by foolish habits of rocking and shaking. 
The rocking cradle has not yet been consigned to its 
merited banishment from all nurseries, and the vigor 
with which some mothers shake their babies up and 
down, especially after nursing, with the idea of keeping 
them quiet (!), is worthy of a better cause. In many 
cases these unfortunate infants simply suffer from 
what would be called seasickness in adults, in others 
the food is actually jolted out of the stomach. Many 
of these babies can be cured by merely laying them 
down to sleep, after meals, instead of harassing their 



DIGESTIVE NEUROSES 219 

nervous systems with rocking and shaking, the educa- 
tion of the mother proving the salvation of the child. 

McClure reports an interesting case of persistent 
vomiting of artificial milk-mixtures in an evidently 
neurotic infant which was promptly checked by giving 
semisolid food. There were no signs of pyloric spasm 
or obstruction, and the stools were normal; we cannot 
emphasize these two points too distinctly, because 
they give the chief clue to the diagnosis in cases of 
this class. 

Orchard reports a case of neurotic anorexia, in an 
infant of eleven months, in which treatment by star- 
vation was successful, after gavage had failed. In the 
second year, similar cases are not so very rare. 



CHAPTER IX. 
DISORDERS OF DIGESTION (Continued). 
ALIMENTARY DISORDERS. 

We designate as alimentary disorders those diges- 
tive disturbances that are due to the ingestion of 
unsuitable food; as regards infantile conditions, this 
practically always signifies the indigestion of cow's 
milk, either plain or modified. Before beginning a 
general discussion of this subject it will be necessary, 
at the risk of repeating much that has been already 
told, to take up, one by one, the various constituents 
of cow's milk and see how they may severally, or in 
combination, lead to derangement of the infant's 
digestion. 

The Proteins. — The proteins rarely, if ever, give 
rise to trouble. We have seen that the old belief in 
the indigestibility of casein has been effectually 
shattered and that the subsequent endeavor to impli- 
cate the whey proteins has met with a similar fate. 
Even sick babies have very little difficulty with the 
proteins, for although Rubner and Heubner seem 
to observe impairment of the protein metabolism in 
atrophic conditions, Fife and Yeeder find it, if any- 
thing, above normal. Holt and Levene show that 



THE FATS 221 

the proteins never cause disturbance, unless given 
in a ratio exceeding 6 per cent., and then only if the 
total food per day measures less than 6 ounces. Now 
the proteins are never given in any such percentage, 
and the total quantity just mentioned involves a 
degree of water starvation that alone is sufficient to 
throw the body metabolism out of gear. Under these 
conditions it is impossible to say how much if any of 
the trouble is directly due to the proteins; it seems 
as if they might safely be left out of consideration so 
far as alimentary disorders are concerned. Morse 10 is 
one of the few leading authorities who still incline to 
the older views. 

The Fats. — Far otherwise is the situation with 
regard to the fats. We have already seen that the 
cow-milk fats present great and, to a certain extent, 
insuperable obstacles to the absorptive powers of the 
infant even in health; we have also seen that these 
difficulties increase in a direct ratio to the fat per- 
centage. From the former asssumption of the entire 
safety of a fat proportion of 4 per cent., the same as 
in human milk, we have been obliged to recede; such 
high authorities as Holt 2 place the danger line very 
much lower in early infancy, and the foreign observers, 
who now call for mixtures rich in fat, content them- 
selves with about 3 per cent. 

There can be no objection to repeating a few facts, 
for example, Freund's 1 observation that the stools 
of bottle-fed infants contain about 50 per cent, of 
soaps — some authors recording as high as 83 per cent. — 
and again calling attention to the concurrent waste 



222 DISORDERS OF DIGESTION 

of calcium and phosphorus. To this may be added 
a note by Meyer 4 to the effect that these losses are 
increased in the presence of gastro-intestinal disease; 
even if Porter thinks that bad fat-absorption is 
due to bacterial infection of the small intestine, 
extending to the pancreas, this merely varies the 
view as to the primary etiology, but does not affect 
the clinical picture of fat-indigestion. We shall see 
that disturbance of function and bacterial infection 
are inextricably interwoven in the severer types of 
alimentary disorders. 

The Carbohydrates. — The true sugars as well as 
dextrin play a lesser part than the fats in the alimentary 
disorders of infancy. We have seen that under strictly 
normal conditions they give rise to no trouble whatever 
unless given in great excess; in the percentages usually 
prescribed these substances are well absorbed and 
assimilated. The situation becomes somewhat different 
when the infant has become ill in consequence of fat- 
indigestion. Finkelstein 4 has shown that in the 
presence of severe intestinal lesions the power of 
absorbing sugar is also impaired, and that in the 
severest types of gastro-enteritis, sugar-intoxication 
predominates over the difficulties of fat-absorption 
and constitutes the chief danger to the infant. This 
matter will be gone into more fully later on; at this 
point it will suffice to remind the reader that the 
sugars, so easily assimilable by normal infants, may 
act as poisons under certain pathological conditions. 

As regards the starches the situation is very different. 
The diastatic ferments of the infant are able to 



THE CARBOHYDRATES 223 

dextrinize only a moderate amount of starch, less than 
1 ounce per day at one month of age, and not above 3 
ounces at three months (Kerley and Campbell): we 
may regard these figures as maxima, the limit for 
most infants being decidedly lower. Excessive starch- 
feeding almost inevitably leads to the condition of 
starch-atrophy (Mehlnahrschaden), so well described 
by Czerny and Keller. Of this clinical picture there 
is no better outline than the following after Keller. 4 
The infant presents a peculiarly dry skin, easily raised 
in folds from the muscles, which are notably rigid 
(hypertonic); the baby hardly moves its limbs and 
the heart action is feeble; there is marked anorexia, 
but no great disturbance of the bowels, particularly 
no diarrhea. The infant's color is not poor in the earlier 
stages, so that its appearance is no guide to the serious 
condition actually present; this feature, along with 
the lack of intestinal symptoms, is specially mis- 
leading. In the last stage there may be distinct signs 
of acetonemia which finally proves fatal, unless life is 
terminated before this by some intercurrent infection, 
to which these infants are extremely liable. 

On careful and critical analysis it is not very clear 
how much of this form of atrophy is due to starch- 
feeding and how much to protein- and fat-starvation; 
probably both factors are engaged in its production, 
as is strongly suggested by a study of the etiology. 
The trouble usually begins in about the following 
way: the baby, which has been fed on some milk- 
mixture, gets an attack of diarrhea; to check this 
the doctor or some kind friend recommends one of 



224 DISORDERS OF DIGESTION 

the starchy baby-foods, whereupon the evacuations 
rapidly become fewer and more solid. Repeated 
attempts to go back to modified milk always cause 
some looseness of the bowels, which is always stopped 
by returning to the baby-food. Finally the latter is 
given exclusively, matters going on fairly well for a 
time until the picture of starch-atrophy is gradually 
developed. Now we have seen in discussing baby- 
foods that they are almost fat-free; it is well known 
that the fats are only very partially replaceable by 
carbohydrates and most inadequately by so indiges- 
tible a carbohydrate as starch. The terminal acidosis 
in these infants is undoubtedly for the most part due 
to the disintegration of the body-fat, which Chittenden 
and Mendel give as the source of the acetone group 
of bodies; the disappearance of the subcutaneous 
fat is one of the most striking features of starch- 
atrophy. Thus the role of fat-starvation is evident, 
the only uncertainty being whether it is accessory or 
only secondary. 

The part played by protein starvation is not so 
certain, for the ratio of the proteins in baby-foods 
is not so very low; they are, however, chiefly vegetable 
proteins, only about three-fourths of which are 
absorbed, so that the available supply is certainly 
not quite up to the requirements. Furthermore, 
atrophic infants, as stated previously, seem to demand, 
if anything, rather more than the normal percentage 
of proteins, and we shall see that a recognition of this 
circumstance is the guiding principle in feeding with 
albumin-milk. In addition to these facts there is 



THE SALTS 225 

good reason to believe that some of the acetone bodies 
are derived from destruction of the body proteins; 
this is more than probable in diabetes (Erving), and 
may well apply to other disturbances in carbohydrate 
metabolism. It is therefore not at all unlikely that 
starch-atrophy also involves a certain amount of 
protein starvation, though this is not yet absolutely 
proved. 

The Salts. — Many disorders of infant digestion 
seem to be related to the excess of salts in most of the 
artificial feeding-mixtures; we have seen that the 
ratio of salts in human milk is considerably lower. 
The entire subject of salt-intoxication is, however, 
for the present in an unsettled state; it seemed quite 
well understood a few years ago, but since then more 
critical study has rendered doubtful some points 
that appeared definitely disposed of, so that I can 
only record the reports of a few of the numerous inves- 
tigators without presuming to register a final verdict. 

The whole matter revolves about the theory of what 
is called salt-fever. Schaps found that the hypodermic 
injection of 5 c.c. of a sterile physiological solution of 
sodium chlorid gave rise to fever which reached its 
acme in about eight hours and subsided within a 
day. Meyer and Rietschel corroborated this finding 
and reported similar results when large quantities of 
the solution were given by the mouth; they showed, 
on the other hand, that the fever could often be averted 
by adding 0.02 per cent, each of calcium and potassium 
chlorids to the salt solution. These experiments 
rendered it very questionable whether the action of 
15 



226 DISORDERS OF DIGESTION 

the salt solution was really toxic or the temporary 
fever was merely a passing chemical reaction of the 
body cells to the salt (Finkelstein 5 ). Finkelstein 5 does 
not regard salt-fever as a distinct condition, but con- 
siders it identical with sugar-fever, the trouble in both 
cases being a transient difficulty in absorption. 

Nothmann 3 shows that although the ingestion of 
a 1 per cent, solution of sodium chlorid can produce 
fever in a young infant, older infants are usually 
affected in this way only by higher percentages. 
Katzenellenbogen says that salt-fever depends much 
more on the concentration of the solution than on the 
quantity of salt. Salge 2 explains the greater suscepti- 
bility, in the earliest months, by the imperfection 
of the osmotic adjustment at that age; the liability 
to salt-fever is increased by disturbed intestinal 
absorption in consequence of starch-feeding or sugar- 
intolerance. Weiland, who in general directly con- 
tradicts Schaps, shows that normal infants do not 
react with fever to isotonic (physiological) solutions 
of either sodium chlorid or sugar. Schlutz claims that 
the combination of salt and milk-sugar causes fever 
only in the presence of intestinal disease. 

E. Schloss 1 submits the following theory of salt- 
fever, namely, that the solution of the surplus sodium 
chlorid in the body fluids causes a rise of temperature 
through the liberation of latent heat. This theory 
of course holds good only if hypertonic solutions, 
containing over 1 per cent, of sodium chlorid, are 
injected or ingested. Heim and John 2 attribute salt- 
fever to heat retention, which is a less accurate way of 



SALT-FEVER 227 

stating the same proposition. Friberger notes that salt- 
fever has usually been due to the hypodermic injection 
of sodium chlorid, whereas large doses may be given 
by the mouth without harm. 

Reviewing the above reports, a mere fraction of 
the extensive literature on this subject, the reader 
will note a number of contradictions, which cannot 
fail to rouse a suspicion: (1) that some of these 
observations are fallacious, and (2) that salt-fever 
is not always a simple matter of osmosis and heat- 
retention. Some of the alleged explanations are mere 
verbiage, masking ignorance of the true cause with 
a haze of scientific terms. 

A rather recent communication by Samelson 2 has 
given some of the above theories of salt-fever a rude 
shock, from which they are not likely to recover. 
He proves that this disturbance is usually, if not 
always, due to toxins and bacteria in the water used 
to make up the solution, and that an 0.8 per cent, 
solution of sodium chlorid in fresh distilled water never 
causes salt-fever. This observation is in accord with 
the experiences derived from the many thousands of 
injections of salvarsan, where similar disturbances 
had been noted, when water that had not been freshly 
distilled was employed as a vehicle. Samelson's views 
have since been corroborated by Bendix and Bergmann 
as well as other authors. 

These more recent findings narrow down the 
question of salt-fever, so far as it is related to infant 
feeding, to two points: (1) the injection or ingestion 
of a physiological salt solution, if properly performed 



228 DISORDERS OF DIGESTION 

in the case of the former, and with moderate total 
amounts in either ease, is harmless to the healthy 
infant; (2) in the presence of carbohydrate intolerance 
the case may he different, the salt probably adding 
to the febrile disturbance already started by the 
carbohydrates. This last point cannot be disregarded, 
for solutions of sodium chlorid are frequently given, 
hypodermically or per rectum, in cases of this group, 
and it is very likely, in view of the above discussion, 
that this treatment actually does harm instead of 
being beneficial, as is generally believed. 

As to the pyrogenic action of concentrated salt 
solutions there is at hand sufficient evidence to estab- 
lish it beyond a reasonable doubt. Clinically, however, 
this is not very important, as hypertonic solutions 
have not been used therapeutically and have played 
but a minor role in the entire discussion. 

It is probable that the last word on the subject of 
salt-fever, remains to be written; our present know- 
ledge is certainly fragmentary, and the latest researches 
have largely impaired our confidence in what remains 
of a once flourishing theory. 

Apart from the question of salt-fever, the salts are 
important factors in infant pathology because of 
their intimate relation to the body's water metabolism. 
This is due to the efforts of the organism to keep its 
fluids isotonic, either by retaining water, or eliminating 
the salts whenever the latter are present in excess; 
similarly a deficiency in the salt supply will result in 
a marked loss of water, but this condition is far less 
frequent. It will be readily understood that the normal 



HALT-RETENTION 229 

moisture of the tissues may be reduced in two entirely 
different ways: (1) The introduction of abnormally 
large quantities of salts into the body may draw off 
great amounts of water from the tissues; this is accom- 
plished through the kidneys and intestine, to a less 
extent through the skin, and is the basis on which 
we administer various salts for diuretic and purgative 
purposes, when we desire to reduce the amount of 
fluid in the body; (2) the body tissues may become 
more or less desiccated by salt-starvation, and this 
may be one of the factors that cause the clinical 
picture of starch-atrophy from the use of baby-foods. 

Under certain circumstances the body is unable to 
get rid of an excess of salts; this occurs, in its most 
typical form, when the renal functions are suspended, 
but may also be a consequence of certain toxic and 
hitherto unexplained conditions. As the salts accumu- 
late in the body they attract sufficient water to maintain 
themselves, as nearly as possible, in an isotonic solution 
which gradually fills the subcutaneous spaces and 
serous cavities, producing what we call edema and 
anasarca. Krasnogorski gives the following three 
stages of this process as it occurs in infancy: 

1. The weight becomes stationary or fluctuates: 
this condition is aggravated by increasing the carbo- 
hydrates or salts in the food; the normal relation 
of the salts and water of the tissues is evidently 
disturbed. 

2. There is a large gain in weight for some days 
if carbohydrates and salts are given in excess; if these 
substances are withdrawn the weight again falls. The 



230 DISORDERS OF DIGESTION 

tissues no longer resist the process of water-logging, 
and we have the condition of latent edema. 

3. Clinical edema: the water is not assimilated 
and the body weight depends largely on the degree 
of edema. Meanwhile the kidneys may be perfectly 
normal. 

All three stages are attributed by Krasnogorski 
to errors in the salt metabolism, and he designates 
them accordingly as Salznahrschaden, i. e., salt- 
atrophy. 

We shall recur to these matters when we discuss 
therapeutic measures, but at this point we must bear 
in mind one circumstance which has probably already 
impressed the reader: It is to the effect that the 
carbohydrates and salts must, to a certain extent, be 
added together in studying the body's water metab- 
olism; both enter the tissues in the same way and 
both require definite amounts of water for their solu- 
tion. In considering the disturbances of the fluid 
balance of the organism as a whole, the sugars and 
salts cannot be separated, as will be illustrated more 
fully later. 

Let us now summarize briefly what has gone before. 
We have seen that the infant's digestion may undergo 
various derangements through the endeavor to raise 
it on an unsuitable food, namely, cow's milk, given 
plain or modified; we have also seen that the different 
ingredients of cow's milk are not hurtful in the same 
degree, the fats being evidently the usual and pri- 
mary source of trouble, the carbohydrates playing a 
secondary part, the salts being in a subsidiary or 



FINKELSTEIN'S THEORY 231 

supplemental role, and the proteins rarely, if ever, 
creating disturbance, even under adverse conditions. 
What we next need is to combine these facts, so plainly 
correlated, and to construct from them a single clinical 
picture; to have done this successfully is the signal 
merit of Finkelstein and his school; however minor 
details may be disputed, the following framework, 
built up by these investigators, is likely to be of con- 
siderable permanence. 

FINKELSTEIN'S THEORY. 

Finkelstein 6 takes up the general idea of Milch- 
nahrschaden, i. e., milk-atrophy, at the point where 
Czerny and Keller left it, and carefully analyzes its 
stages of development. These stages he characterizes 
by their leading clinical symptoms, as well as their 
digestive pathology. We thus obtain a steady grada- 
tion from the milder and simpler types of digestive 
disorder to those of greater severity and intricacy. 
Finkelstein also notes the various modes of treatment, 
as adapted to these different stages, a refinement that 
has been of inestimable aid in therapeutics, and, 
finally, he has given us a scheme of diet for the grave 
disturbances, which is not only founded on sound 
principles, but has been the means of saving thousands 
of infants from a condition apparently hopeless, as 
well as expediting the recovery of such cases as are 
in a less desperate state. 

I. Disturbed Equilibrium. — The first symptom of dis- 
turbed alimentary equilibrium is an irregularity in the 



232 DISORDERS OF DIGESTION 

weight curve; the baby occasionally fails to score its 
regular weekly gain or alternates between good and 
bad weeks, with the net result of gradually falling 
below normal, although the food-supply is adequate. 
Increase of the food, particularly of the fats, with a 
view to increasing the weight, always has the opposite 
effect, making the disturbance more pronounced. 

Sometimes the stools are approximately normal, 
more usually they partake of the character of typical 
soap stools, being dry, light-colored, and somewhat 
constipated. Indeed, this stage is characterized by 
impaired absorption of the fats alone; the carbo- 
hydrates are still tolerated, if not given in excess 
or in the form of starch, but errors in this direction, 
namely, the endeavor to compensate the fat deficit 
with a large allowance of carbohydrates, is one of the 
main factors in leading the infant on to the second 
stage. In this respect the starches are most dangerous, 
whereas the malt preparations involve relatively little 
risk. 

The temperature is no longer absolutely normal. 
Whereas it should range between 98° and 99.4° F., 
with daily fluctuations not exceeding 1°, in disturbed 
equilibrium we often see slight rises to 100° and 
morning remissions below 98°. 

Treatment. — The best treatment of this stage of 
alimentary disturbance is, of course, a change to 
breast-feeding, which is sure to cure the condition 
promptly unless the baby is suffering from some con- 
stitutional defect like the exudative diathesis, but 
even in this event an improvement may confidently 



FINKELSTEIN'S THEORY 233 

be expected. Our next best recourse is to cut down 
the fats. If the trouble is due to venturesome attempts 
with top-milk feeding the fat allowance may be radically 
reduced by using mixtures made with whole milk. 
If, on the other hand, we have already been giving 
the latter, which are by no means a sure preventive 
of this disturbance, a proper adjustment becomes 
difficult, as we cannot cut out the fats indefinitely, 
skim milk or buttermilk being a very insufficient food, 
adapted only to very temporary use. Probably the 
best procedure in these cases is to go over at once to 
malt-feeding, letting the baby's entire carbohydrate 
allowance consist of dextrin and maltose. This change 
is usually very effective in clearing up the situation, 
especially if resorted to at the very commencement 
of trouble; the absorption of fat improves, and the 
stools become less typically soapy, though it must 
be understood that the elimination of all of the excess of 
calcium soaps is an impossibility with artificial feeding. 

Should malt-feeding fail we have no refuge save in 
the temporary use of skim milk and buttermilk. In 
giving these we must be careful to avoid excessive 
carbohydrate percentages, for the reasons stated above, 
7 to 8 per cent, being the limit of safety. One of the 
worst mistakes imaginable is the substitution of a 
starchy food of the Nestle type, for the change from 
a condition of disturbed equilibrium to what we have 
learned to recognize as starch-atrophy can hardly be 
said to afford any advantage. 

II. Dyspepsia. — The second, or dyspeptic stage, is 
always preceded by the one just described, but the 



2.U DISORDERS OF DIGESTION 

transition is often so rapid that, in default of a good 
clinical history, the dyspepsia may seem primary. 
Disturbed equilibrium sometimes appears to be merely 
a transition; this is apt to be the case when mistaken 
attempts are made to relieve it by increasing either 
the fats or carbohydrates; Finkelstein distinguishes 
such types as fat-, sugar-, and starch-dyspepsias. 

In dyspepsia the infant is no longer able to digest 
the normal quantity of food, and the weight becomes 
stationary, or even enters on a gradual decline, 
occasionally interrupted by trivial gains. The tem- 
perature becomes still more irregular, with occasional 
rises to above 100° F. 

In this stage intestinal fermentation sets in, which 
some attribute to exogenous bacterial infection, but 
Finkelstein believes to be usually due to inability of the 
intestine to maintain its normal flora; the fermentative 
bacteria, whose numbers are kept at a minimum under 
normal conditions, now begin to get the upper hand. 
^Yhen this takes place a catarrhal condition of the 
intestinal mucous membrane follows, as a matter 
of course; the stools may still be only moderately 
numerous, but showing every evidence of greatly im- 
paired fat digestion, or may become truly diarrheal. 

Though fat-dyspepsia sounds the key-note during 
this stage, there are already some signs of impaired 
absorption of the carbohydrates; the fermentative 
processes attack the ingested sugars, leading to a 
considerable formation of gases, with resulting colic; 
it is very clear that the readily fermentable starches, 
under these conditions, will give more trouble than 



FINKELSTEIN'S THEORY 235 

milk-sugar and cane-sugar, and these again more than 
malt, which does not ferment easily. 

The symptomatic dividing line between dyspepsia 
and the next stage is not always sharply defined; the 
distinction is often rather in degree than in kind; but 
the very slight and gradual loss of weight in merely 
dyspeptic disturbance is a valuable criterion. 

Treatment. — Breast-feeding is here also the sovereign 
remedy, sure to cause rapid improvement. If there 
is no opportunity to turn to breast-feeding we must 
resort to skim milk or, still better, buttermilk, but 
without the addition of carbohydrates, for fear of 
hurrying the disorder onward to the next stage. 
Superior to either is the substitution of malt for the 
ordinary sugars; it is in this condition that Keller's 
malt-soup has proved so eminently successful; we 
have shown how effective dextrin-maltose mixtures are 
in checking the progress of intestinal fermentation. 
Keller's method is of course, as previously mentioned, 
merely a temporary device, to be employed for some 
weeks only. 

If the dyspeptic stage shows no improvement within 
a week, the infant is in imminent danger of going over 
into the following condition. 

III. Atrophy (Decomposition, of Finkelstein). — In 
various parts of this manual I have employed the 
word atrophy to translate, rather inadequately, the 
German term Nahrschaden, which cannot be rendered 
by an exact English equivalent. The third stage of 
impaired nutrition in the classification of Finkelstein, 
called by him Decomposiiion, is recognized by him as 



23G DISORDERS OF DIGESTION 

identical with what has always been called atrophy. 
In this stage anything like proper nutrition has become 
impossible; the loss of weight is rapid, an ounce or 
two per day; the infant cries incessantly, from hunger 
as well as general discomfort, and manifestly suffers 
from starvation, as it takes proffered food greedily. 
The skin is pale, the oral mucous membrane reddened. 
The temperature becomes very irregular, with a marked 
tendency to be subnormal, going down to 97° F., and 
even lower. 

The evacuations vary greatly; they may not depart 
so very much from the normal, but this is rare; more 
commonly they are soapy, or evidently undigested; 
fat-diarrhea and tarry (bloody) stools are not uncom- 
mon. The pulse is rather slower than normal; the 
respiration at first shows prolonged expiration, then 
irregularity, occasionally being of the Cheyne-Stokes 
type. There is no evidence of any renal lesion, but 
an edema or anasarca of metabolic origin may never- 
theless be present. Sometimes the infant becomes 
cyanotic. 

This stage often proves fatal, either from sudden 
collapse or from acute inanition, with a rapid fall in 
the weight and temperature that lasts for a few days, 
or from an intercurrent infection, to which atrophic 
babies are particularly liable. Finkelstein differs from 
some authors, who think that an infection is essential 
to a fatal outcome; he regards the mere atrophy as a 
sufficient cause of death. 

In the stage of atrophy the absorption of fat is 
reduced almost to zero and the tolerance to carbo- 



FINKELSTEIN'S THEORY 237 

hydrates has begun to suffer severely; concurrently 
there is more or less disturbance of the salt-metabolism, 
as is shown by the tendency to edema and anasarca. 
It is not improbable that the worst cases may exhibit 
a diminished tolerance for proteins, though this has 
not yet been proved. 

Treatment. — Even the resort to breast-milk may fail to 
save a severely atrophic infant; indeed, the end may be 
hastened by full breast-feeding, because even the human 
milk-fats are now badly tolerated. We must often begin 
with small allowances, drawn with the breast-pump, 
not giving more than an ounce or two at a feeding 
to commence with, and in the worst cases even less. 
As to artificial feeding, the treatment outlined for 
dyspepsia, especially the method devised by Keller, 
may be successful in cases that are not too far ad- 
vanced; in some of these we may eventually return 
to an ordinary whole milk formula. In bad cases the 
Keller treatment is only temporarily successful, some- 
times even harmful, from the high ratio of carbohy- 
drates, and a relapse invariably follows any attempt 
to return to a really sufficient diet, so that the saving 
of the baby becomes a problem of extreme difficulty. 
In the very worst cases, Keller's malt-soup utterly 
fails to achieve any improvement, and the infants are 
lost unless breast-milk is at hand to save them. 

It will not be amiss to add a few words of caution 
against treating these cases with a preliminary course 
of starvation. This treatment is highly effective, if 
limited to twenty-four hours, in intestinal infection or 
intoxication, but it is utterly out of place in atrophy, 



238 DISORDERS OF DIGESTION 

of which a form of chronic starvation is the essential 
feature. This is clearly pointed out by Rosenstern. 2 

IV. Intoxication. — The relation of the stage of in- 
toxication to the three others is very far from obvious, 
and represents the vulnerable portion of Finkelstein's 
theory. He regards it as essentially a continuation 
of the preceding stages, but we do better to regard 
it as a sequel or complication that may follow in the 
wake of either dyspepsia or atrophy. 

In intoxication we encounter a feature that has so 
far been relatively inconspicuous, namely, an almost 
total intolerance for sugar; on the other hand the 
power of absorbing fat is somewhat better than in 
atrophy, and more like that in mere dyspepsia. The 
protein digestion is practically unimpaired. 

Symptoms. — As to the general symptomatology 
the most marked feature is fever, of a very irregular 
type, but sometimes reaching very high degrees. 
The respiration is deep and hurried, often panting, 
so that Finkelstein feels justified in speaking of 
asthma dyspepticum, a symptom first described by 
Henoch. The pulse is rapid and feeble, so that collapse 
seems imminent; the blood shows a moderate leuko- 
cytosis, rarely exceeding 30,000. 

Diarrhea is present, in varying intensity, ranging 
from moderately frequent undigested stools to very 
numerous rice-water evacuations; if collapse sets in 
the diarrhea may stop. In the urine we find albumin 
and casts, sometimes also sugar, but in this event always 
lactose or galactose, never dextrose, as in diabetes; 
the lactosuria furnishes evidence that the food sugar 



FINKELSTEIN' S THEORY 239 

is badly assimilated, even when absorbed, because of 
impairment of the glycogenic function. There is of 
course a rapid loss of weight, so that the infant soon 
becomes extremely emaciated. 

Symptoms referable to the nervous system are 
common. Somnolence is frequent, and may pass on 
to stupor and coma; cataleptic conditions are often 
encountered, as are convulsions; the nervous symp- 
toms are not always in proportion to the gravity of 
the disease. According to the predominance of one 
or another group of phenomena, Finkelstein divides 
alimentary intoxication into several clinical types, 
such as the choleriform, soporous, hydrocephaloid, and 
asthmatic. 

In reviewing the above account of the stage of in- 
toxication the American reader will have no difficulty 
in recognizing the clinical picture, known to him as 
acute enterocolitis, summer diarrhea, and cholera 
infantum. The centre of interest in this connection 
lies in the stand-point of Finkelstein, that we are 
dealing with a terminal stage in an alimentary dis- 
turbance, for which the stages of disturbed equilibrium, 
dyspepsia, and atrophy have been preparatory. It 
is undoubtedly true that intoxication is nearly always 
preceded by other types of digestive derangement, 
but I must agree with the many authors who do not 
regard it as a mere terminal outcome. One very weak 
point in Finkelstein's position is the circumstance 
that the fats are usually better tolerated in the fourth 
than in the third stage; this is certainly very curious 
and unaccountable, demanding an explanation which 



240 DISORDERS OF DIGESTION 

Finkelstein has failed to supply. Furthermore, a 
whole series of symptoms points to a bacterial infection 
as the essential factor in causing intoxication; among 
these I may mention the fever, leukocytosis, cerebral 
phenomena, and evidences of nephritis, not to speak 
of the fact that a number of demonstrated bacterial 
diseases give us exactly the same clinical picture. I 
therefore regard the attitude of Talbot 1 as reasonable 
when he considers the stage of intoxication an exogenous 
infection, grafted on to a digestive disturbance, but 
not a merely higher degree of the latter. Finkelstein 
himself has admitted that infants who suffer from the 
earlier stages are exceedingly subject to the invasion 
of pathogenic microorganisms; he commits himself 
seriously when he speaks of the fourth stage as an 
auto-intoxication. Modern views are becoming very 
conservative on the subject of auto-intoxication; no 
less an authority than Adami doubts the very existence 
of enterogenous forms of this affection, declaring that 
the action of invading organisms is absolutely essential 
to the production of toxic symptoms in intestinal 
disease. Clincially, however, Finkelstein's view has 
some justification; he stands on fairly firm ground 
when he maintains that a previously disordered 
digestion always precedes the development of the 
stage of intoxication, and that bacterial infection 
cannot take place if the mucous membrane of the 
gastro-intestinal tract is in a healthy condition. We 
have seen that the predominance of the lactic acid 
bacillus, the controlling germ of the normal intestinal 
flora, is inimical to the growth of other microorganisms; 



FINKELSTEIN'S THEORY 241 

it is therefore altogether likely that a severe disturbance 
of function, and a catarrhal condition of the mucous 
membrane, are indispensable prerequisites for an 
alteration of bacterial conditions and the development 
of the processes here under discussion. 

Whatever conclusion may eventually be reached, 
one important observation of Finkelstein is likely 
to hold good, namely, that the carbohydrates act as 
the toxicogenic substance in alimentary intoxication 
and that their withdrawal is the chief requirement 
of successful treatment. This is in itself no incon- 
siderable achievement, and in support thereof, Finkel- 
stein and his followers have furnished ample proofs. 
The studies on salt-fever, previously discussed, although 
they have not hitherto led to satisfactory conclusions, 
do not in any way invalidate the main proposition, 
but in fact strengthen it, since it has generally been 
accepted that the carbohydrates and salts must be 
added together in considering the disturbances of the 
water metabolism, which play so important a role in 
alimentary intoxication as sometimes to come into the 
foreground, as in the choleraic type. 

Treatment. — The treatment of this condition is 
a logical sequence of the etiological determinations 
outlined above, but will not be detailed in this place, 
because we desire to avoid repetition. We can take 
it up to better advantage when we proceed to discuss 
the various forms of intestinal infection in the follow- 
ing chapter, where the clinical picture, which has 
just been sketched, will be presented more fully from 
the bacteriological point of view. 
16 



242 DISORDERS OF DIGESTION 

Finkelstein's researches have led to far-reaching 
and epoch-making progress in various other directions. 
They have administered the quietus to the view that 
casein causes digestive trouble, and have led to the 
intensive study of salt-fever, discussed in a previous 
paragraph. The best result has been a more rational 
and successful treatment of the most severe forms of 
gastro-intestinal disease, worked out through clinical 
experience and not based on preconceived theories. 
We shall see that the most recent investigations have 
furnished a scientific basis for the good results that 
have been obtained, but the net outcome is one more 
example of the superiority of bedside observation, 
when intelligently conducted, over uncontrolled labora- 
tory research and mere reverence for authoritv. 



CHAPTER X. 
DISORDERS OF DIGESTION (Concluded). 

INFECTIOUS DISORDERS. 

The third great group of digestive disorders is 
caused by the invasion of the gastro-intestinal tract 
by pathogenic bacteria. Practically these bacteria 
gain access to the body only through one source, 
namely, the food; therefore, from the nature of the 
case, the diseases here considered must be chiefly 
associated with artificial feeding. They are conveyed 
to the infant either by infected milk or through 
uncleanliness in feeding, whereby otherwise innocuous 
milk is inoculated with disease germs. This is the 
reason why, in a previous chapter, detailed advice was 
given as to scrupulous cleanliness in the manipulation 
of bottles, nipples, and the other paraphernalia that 
are employed in bringing up infants on cow's milk. 

Through bacteriological researches it has now been 
definitely ascertained that there are several forms of 
infectious intestinal disturbance in infants; if we here 
decide to discuss them together it is because their 
differentiation is difficult, their symptomatology is 
similar, and their treatment not very diverse, whereas 
the prophylaxis is practically the same for all. 

Etiology. — Let us begin with a consideration of the 
predisposing causes. First among these is the presence 



244 DISORDERS OF DIGESTION 

of one of the milder degrees of alimentary indigestion. 
It was formerly believed that infectious diarrhea would 
attack a normal infant almost as readily as one whose 
digestive apparatus was already more or less disordered, 
but experience and investigation have shown that 
this is, strictly speaking, not the case. For practical 
purposes, however, this consideration is not so impor- 
tant, as it would seem; undoubtedly the majority 
of bottle-fed babies are not raised according to the 
most approved methods, and a very large percentage 
is always suffering from the condition described as 
disturbed equilibrium. We have seen how this is apt 
to pass on, in some cases quite rapidly, to the stages 
of dyspepsia and atrophy, which admittedly predis- 
pose to bacterial infection. It is therefore not remark- 
able that even badly managed breast-fed babies rarely 
suffer from this disease, since the chief predisposing 
factor is usually lacking in them, even though their 
intestinal functions may not be quite normal. 

The second predisposing cause is warm weather, 
which does not by any means imply intense or tropical 
heat, but does require a certain degree of atmos- 
pheric humidity to become effective. The sensible 
temperature, a mathematical function of temperature 
and relative humidity, is more important than the 
ordinary temperature as indicated by the dry-bulb 
thermometer. Dry heat is comparatively harmless. 
Thus a temperature of 80° with 80 per cent, of humidity 
represents the same sensible temperature as 95° with 
40 per cent, of humidity, and is equally injurious. 

So influential is this factor that infectious intes- 



INFECTIOUS DISORDERS 245 

tinal disease is generally spoken of as summer diarrhea, 
though similar eases occur, but far less frequently, in 
the cooler months. In the days when infant hygiene 
was indeed in its swaddling clothes, this country, 
especially the larger American cities, had a most un- 
enviable reputation for a high infant mortality from 
diarrheal diseases during the summer season. This 
was attributed in part to American heedlessness in 
general, but in part most justly to the heat and 
humidity, which we had, in those days, no means of 
guarding against. As a matter of fact, the summer 
of our three leading cities is fully 8° F. warmer than 
that of the three greatest European capitals, and the 
humidity is, if anything, also slightly higher in the 
former. 

Among the first to present reliable data on this 
subject was Seibert, who constructed a chart showing 
the death rate from diarrheal diseases in infants and 
young children, in New York City, month by month. 
The rate remains uniformly low until the middle of 
May, when the mean temperature has reached 60° 
F., a steady rise then takes place until the latter part 
of July, when the average temperature is highest; 
then a decline begins, which grows rapid in September; 
in early October the mean temperature has again 
fallen to 60°, but this month still shows a higher death 
rate than the months from November to April, because 
of a number of chronic cases that hold over from the 
summer to succumb in the fall. 

Some years ago I 3 drew up a similar chart, based 
on the sensible temperature, the details of which do 



246 DISORDERS OF DIGESTION 

not differ materially from those of Seibert. The danger- 
line, according to the sensible temperature, is a little 
lower, about 55° P. 

European cities, north of the Alps and Pyrenees, 
furnish similar death-rate charts, but with greater 
annual variations. The ordinary north European 
summer has a mean temperature not so very much 
above 60°; the mortality therefore rises more slowly 
and does not attain its maximum until August, because 
the type of infection is not so acute nor so rapidly 
fatal. In cool summers, which seem very chilly indeed 
to an American, the rise in the death rate in such 
cities as London, Paris, or Berlin is very small; in 
hot summers, as in 1911, the chart resembles that of 
American cities. I may note that in New York City, 
in recent years, not only has the crest of the mortality 
curve fallen considerably, but the maximum has 
shifted to August, even when the hottest weather 
occurred in July. This would indicate that the ful- 
minant cases of cholera infantum have been largely 
replaced by the subacute and less rapidly fatal forms 
of intestinal infection, and I am sure that most local 
physicians will bear me out in this opinion. As our 
climate has not changed, some recent summers, as 
that of 1911, having indeed been exceptionally warm, 
it would appear that the evil influence of mere heat 
is, to a great extent, controllable, and that its role 
is merely predisposing, not directly provocative of 
diarrheal disease. 

There are still many authors, such as Schereschewsky 
in this country, and Rietschel in Germany, who con- 



INFECTIOUS DISORDERS 



247 



sider hot weather, and especially overheated lodgings, 
as a direct exciting cause; they regard the most acute 
forms of cholera infantum as phases of heat-stroke. 
Aside from the symptomatology, in which these cases 
do not in the least resemble heat-stroke, it has been 
often noted that the greatest mortality does not 
coincide with the hottest weather. It should be remem- 
bered that heat-stroke consists of simple hyperpyrexia, 
induced directely by the influence of intense heat, 
which the organism is unable to counteract by radia- 
tion and perspiration. The following records for New 
York illustrate the true relation of these matters: 



Months. 


July, 
1911. 


Aug., 
1911. 


July, 
1912. 


Aug., 
1912. 


Julv, 
1913. 


Aug., 
1913. 


Temperature, Fahrenheit . 


77 


73 


76 


72 


76 


73 


Sensible temperature .... 


68 


67 


67 


Co 


68 


66 


Deaths from heat-stroke . 


535 


17 


75 


6 


44 


12 


Deaths from diarrheal diseases 














(under five years) .... 


809 


1034 


771 


925 


598 


807 



We see that the deaths from heat-stroke coincide 
with the high temperatures, but that the mortality 
from diarrheal diseases shows no such intimate rela- 
tion. The high heat-stroke figure for July, 1911, was 
caused by an extraordinary hot spell during the first 
half of that month, but at the same time the infant 
mortality was about as usual. 

The best disproof of the heat-stroke theory is 
furnished by the statistics of New York City, where 
the decline in morbidity and mortality from summer 



248 DISORDERS OF DIGESTION 

diarrhea has been enormous, though the climate has 
not changed, and the rooms of our tenements are 
pretty much the same malodorous sweat-boxes that 
they were ten or twenty years ago. 

Hot weather acts chiefly as an indirect cause, in 
that it favors the growth of pathogenic and putre- 
factive bacteria in the milk. If this article of food 
could be obtained in a nearly aseptic way and kept 
cool, so as to hinder the growth of the relatively small 
number of contained germs, the harmful effects of 
mere warm weather could be almost entirely obviated. 

We pass on to the one exciting cause, the bacteria 
in polluted milk. We have already discussed the 
question of milk-supply quite fully, and need only 
repeat that in every community the decline in infant 
mortality has strictly coincided w T ith the improved 
supervision of that food. Results that at first seemed 
incredible w T ere reported from such cities as Rochester, 
New York, which was one of the first to adopt a system 
of really adequate milk-inspection. Since then the 
same effect has been observed in every community 
where similar methods have been adopted. 

Rietschel is undoubtedly right when he claims that 
mere dirt in the milk does not cause intestinal infection, 
but, after all, this objection is purely academic. All 
impure milk, as well as some that passes muster, is 
liable to contain disease germs, and this is indeed 
the chief argument for the enforcement of universal 
pasteurization. These views are gaining ground so 
rapidly as to convert even those authorities who, on 
a theoretical basis, prefer high-grade raw milk as in 



INFECTIOUS DISORDERS 249 

many respects a better food. Many of the former raw- 
milk advocates are now advising pasteurization of even 
the best quality of milk, at least during the summer 
months. 

Since pathogenic bacteria are the direct cause of 
intestinal infection, let us pass on to a study of their 
various species and manifestations in detail. 

In 1898 Shiga found a microorganism ca led the 
Bacillus dysenteric in cases of ordinary dysentery, 
as met with in Japan, thus showing that there were 
two forms of so-called tropical dysentery, the bacillary 
and the amebic, Shiga's bacillus being the cause of 
the former. Soon after Flexner, in the Philippine 
Islands, found a somewhat different bacillus in the 
same disease; this variety of the Bacillus dysenteric 
is distinguished as the type Flexner, or Flexner-Harris. 
Since then another variety, called Type Y, has been 
found, and Ohno, reporting from the Philippines, 
shows that there are at least fifteen varieties of this 
bacillus, all closely related to one another in mor- 
phology and pathogenicity. 

A few years afterward the above discoveries were 
brought into relation with the subject before us. 
In 1902 Duval and Bassett found the Bacillus dysen- 
teric in the evacuations of cases of summer diarrhea 
in infants, a discovery that soon received ample con- 
firmation. A comprehensive study of this question 
is furnished in the report of Flexner and Holt, where 
cases due to all three of the above-mentioned types 
are recorded, the culture findings being confirmed 
by serological tests. A few special points may be 



250 DISORDERS OF DIGESTION 

emphasized. In the first place, dysentery is reported 
in breast-fed infants; in these cases the infection cannot 
have taken place through the milk, but must have 
been transmitted through uncleanliness in some other 
respect. Some cases were observed in the cool months, 
and ran the same course as the typical summer infec- 
tions. A previous lesion of the intestinal mucous 
membrane seems to be essential; in the normal intes- 
tine the bacilli of dysentery lead a merely saprophytic 
existence, ready to create a severe disturbance as soon 
as a digestive disorder has set in; this is in accord 
with the findings of Finkelstein, 6 reported a few years 
later. It is doubtful if the bacillus can be isolated 
from the evacuations of normal infants except such 
as have but recently recovered from a diarrheal attack; 
the bacillus is none too numerous in the acute cases, 
and its cultivation depends greatly on the skill of the 
investigators, the most expert of whom have found 
it in over 90 per cent, of all cases. 

In temperate climates the Flexner type is commonest, 
such is also the testimony of Weaver and TunniclifT 
and Wollstein; many German observers have not 
found the Shiga type at all (Knopf elmacher, Leiner). 
Of interest is the recent finding, in many cases, of a 
gas-forming bacillus; in the present series of researches 
this bacillus was purposely eliminated, as interfering 
with the cultivation of the Bacillus dysenterise, and 
thus a matter of great importance was ignored by the 
earlier investigators. 

Some years afterward Kendall and Smith came out 
with an interesting report in which they claimed a 



INFECTIOUS DISORDERS 251 

pathogenicity, similar to that affirmed of the dysentery 
bacillus, for the gas-forming bacillus (Bacillus perfrin- 
gens). This germ is sometimes found in immense 
numbers in diarrheal stools, and may be easily isolated 
by cultivating in milk that has been heated to 80° 
C. (176° F.). The Boston observers have been dwelling 
on this point ever since, and confirmation of their 
findings would be very desirable, as in some epidemics 
the dysentery bacillus is either uncommon or very 
hard to isolate. Among other bacteria, streptococci 
have been charged with producing summer diarrhea 
(Knox and Schorer), but their role, as well as that 
attributed to the ubiquitous Bacterium coli, cannot, 
for the present, be absolutely determined. 

Kendall has shown that different bacteria prevail in 
different years, but R. M. Smith points out the diffi- 
culties in the way of the practical utilization of this 
circumstance, since the symptoms show no correspond- 
ing variation. 

Pathology. — According to the various development 
of the intestinal lesions, Flexner and Holt distingu'sh 
four types of pathological findings : 

1. The lower ileum and cecum are lined with an 
extensive pseudomembrane, consisting of necrotic 
tissue, cells, and bacteria, but little or no fibrin (typical 
dysentery) . 

2. There is extensive hyperplasia of the lymphatic 
tissue, but little involvement of the mucosa and a few 
small ulcers. 

3. There is superficial necrosis of the whole mucosa, 
but no pseudomembrane. 



252 DISORDERS OF DIGESTION 

4. The most frequent type: there is only slight 
hyperplasia of the lymphatic tissue. This is the 
common finding in cases that have been already ill 
before the acute symptoms appear, and which succumb 
rapidly. 

Rotch 3 claims that the bacillus of dysentery is 
specially associated with ileocolitis and is not likely 
to occur in merely fermentative diarrhea; he asks 
us to distinguish between these pathological types 
as being etiologically different. In this he disagrees 
entirely with the findings of Flexner and Holt, whose 
position is being more and more sustained as obser- 
vations multiply. Any sharply drawn lines, among 
the four types given above, are quite artificial and 
clinically useless; the old collective term of summer 
diarrhea, without histological specifications, is still a 
practical and adequate designation. 

Symptoms. — We have already studied the symptoma- 
tology of the severe cases in describing alimentary 
intoxication in the preceding chapter, and have noted 
that there is no clinical difference between that dis- 
order and the one we are now discussing. It will, 
however, be of advantage to go into some of the 
details of the specific bacterial infections. Michael 
observes no difference in symptoms between the 
Shiga and Flexner types of infection, and La Fetra 
and Howland agree with him; Park 1 differs from them 
in considering the Shiga type more severe. Knox 
goes into the diarrheal symptoms more minutely and 
finds that mucus is always abundant if severe intes- 
tinal lesions are present, and that the amount of 



INFECTIOUS DISORDERS 253 

blood and pus in the evacuations is fairly proportional 
to the extent of ulceration; small quantities of pus 
may, however, escape notice. Blood and pus rarely 
occur separately, and are met with only after the colitis 
has lasted two or three weeks; we have seen that the 
severest cases do not last so long, proving fatal before 
actual ulcers have time to form. Nephritis is common 
in the worst types, and edema is an ominous sign that 
is independent of the degree of the nephritis, and may 
appear without it (Potter). 

The usual clinical picture may readily be grasped 
from what has been said. After a period of unstable 
weight, with soap stools or moderate diarrhea, corres- 
ponding to what has been called disturbed equilibrium 
or dyspepsia, the infant suddenly goes over into the 
stage called either intoxication or intestinal infection, 
with or without a short intermediate stage of atrophy. 
There is more or less irregular fever, the loss of weight 
is very rapid and continuous, amounting to a pound 
in a few days; the stools are frequent, at first diarrheal, 
ten to twenty or even more per day, finally becoming 
watery (choleraic). At this stage collapse is apt to 
set in, with possibly subnormal temperatures, which 
are of unfavorable import. From this point on, three 
different courses are possible: (1) the infant may 
succumb in a few hours or a few days at the most; 
(2) the diarrhea may cease, the fever gradually sub- 
side, with a marked steadying of the temperature and 
weight curves, and the patient progress to a slow 
recovery; (3) the symptoms may undergo a slight 
abatement, but diarrhea continues, the stools gradually 



254 DISORDERS OF DIGESTION 

begin to show quantities of mucus, later on blood and 
pus, the weight still continues to fall, though a little 
more slowly. Cases of the third group may either 
recover finally, after a long convalescence, during 
which they are in constant danger of a relapse, or 
they may go on to a chronic colitis, and atrophy 
(Decomposition of Finkelstein), with a fatal termination 
after some weeks or months. 

Prognosis. — Most of the statistics that relate to the 
prognosis of infectious diarrhea are vitiated by the 
error of including all the cases of intestinal disease 
that occur during the summer. Now if we include 
the relatively harmless diarrheas met with in breast- 
fed infants, as well as the mild cases, with nearly normal 
temperatures that represent merely intestinal dyspepsia, 
the mortality is only very moderate. So soon, however, 
as we limit our statistics to the truly infectious cases, 
adopting as our criterion a repeated rise of temperature 
above 101° F., the prognosis becomes very doubtful. 

It is evident that we must subject the statistical 
reports to a searching analysis. Thus Dunn, 2 using 
the criterion just mentioned, classifies 111 out of his 
620 cases as of the infectious type; of these 29 did 
not return, reducing his actual clinical material to 82 
cases; of these 12 are recorded as dead or unimproved, 
the latter being almost equivalent to a death sentence 
in this disease, so that we have a probable mortality 
of 14.5 per cent., whereas the unanalyzed statistics 
for 020 cases yield a mortality of barely 2 per cent. 
In the report of Flexner and Holt we find an account 
of 207 cases in whom the bacillus of dysentery was 



INFECTIOUS DISORDERS 255 

actually demonstrated, with a death rate of 35 per 
cent. The last figure fairly represents the mortality of 
bacillary infection under the then prevailing methods 
of treatment. Accurate and carefully analyzed reports, 
based on the more modern therapeutic procedures, 
are not yet extant, but the prevailing impression, as 
well as the picture afforded by recent urban mortality 
statistics, seems to indicate that during the last few 
summers the death-rate has been considerably reduced. 

A point that appears to be of some prognostic 
value is mentioned by La Fetra and Howland, namely, 
that the previous condition of the infant is a very 
useful guide; there cannot of course be any doubt 
that a baby already suffering from atrophy has a much 
poorer chance than one that has been merely dyspeptic; 
we may therefore allow the previous history to modify 
our prognosis in the individual case. It goes almost 
without saying that the outlook also varies according 
to the intensity of the symptoms; exceedingly frequent 
watery stools, meningeal symptoms, anomalies of the 
respiration, and edema are all unfavorable signs, 
whereas the prognosis is still very hopeful if only 
gastro-intestinal manifestations are present. Oppor- 
tunities for adequate treatment also influence the out- 
come more favorably than in almost any other disease. 

Prophylaxis. — The prophylaxis of intestinal infection 
is intimately related to the question of the milk- 
supply, which has already been discussed. Next 
come the cleanly preparation of milk-mixtures and 
the proper care of the containers, bottles, nipples, 
and so forth, besides an ample provision of ice, 



250 DISORDERS OF DIGESTION 

especially in the summer months. The suppression 
of the house-fly at present occupies the centre of the 
stage, but is of secondary importance if the baby's 
food be kept carefully covered; much of the fly agita- 
tion is pure sensationalism, and due to an endeavor 
to find a short cut to sanitation; if the premises are 
kept clean the flies cannot carry dirt. 

Certain other measures are of great value, but 
require the cooperation of the community and form 
a part of the great social question. First come proper 
home surroundings, particularly for the poorer classes; 
this includes the whole field of tenement construction 
and supervision, and belongs to the State and Municipal 
authorities. Next comes provision for purer air than 
can be found in the midst of our great cities; in this 
regard our sea-coast towns have exceptional oppor- 
tunities which have been utilized, so far, in a manner 
by no means equivalent. Much can be accomplished by 
means of seaside parks, water excursions, and recreation 
piers; a great deal of the progress achieved in such 
cities as New York and Boston can be attributed to 
the development of these resources, but the greater 
part remains to be done. Even more important is 
the instruction of mothers in proper methods of infant- 
feeding and hygiene: (1) in the inculcation of nursing, 
whenever this is at all possible; (2) in teaching each 
individual parent the correct methods of milk-modi- 
fication in the home, or supplying the proper mixture, 
the latter an inferior plan, because too apt to be 
handled in routine fashion. If we succeed besides 
in doing away with certain feeding superstitions that 



INFECTIOUS DISORDERS 257 

are popular with the masses and banish the dirt- 
collecting pacifier, still more will be gained. These 
general measures can only be carried out through milk- 
stations which should, however, not be mere dispensers 
of milk, but should be run on the lines of well-equipped 
hospital dispensaries; they are indeed apt to work 
best if affiliated with the pediatric service of a hospital. 
Milk-stations that are merely presided over by a 
physician, or still worse a trained nurse, and leave 
the details of feeding, as well as the care of the home, 
to ignorant mothers, are of relatively little value; 
home visiting is an absolutely essential part of the 
scheme. Still, I would not discard the old-fashioned 
milk-stations as entirely useless, for they have at 
least the merit of controlling the quality of the milk- 
supply. 

Prominent among prophylactic measures, and 
almost self-evident, in view of the etiological factors, 
is the prompt and adequate treatment of infants 
suffering from disturbed equilibrium and dyspepsia, 
before their intestines become infected. This must, 
for the present, remain largely a vain desire. Some 
mothers think that a moderate diarrhea is normal, 
others believe that their babies are ill from teething, 
still others resort to starch-feeding, with the disastrous 
results before mentioned; last, but not least, come 
the parents who go for advice to solicitous relatives, 
or some self-declared lay expert, in fact to anybody 
except the doctor. I regret to add that instruction 
in infant-feeding in the medical schools is still not 
what it should be, and is very often far behind 
17 



258 DISORDERS OF DIGEST I OX 

the times; too many teachers stick to their own hob- 
bies and do not give the student the benefit of the 
latest researches; in some medical schools the study 
of physiology is neglected in favor of the practical 
branches which, after all, rest on a thorough knowledge 
of the functions of the normal body. Thus many 
members of the medical profession, especially some 
older ones, whose active practice has not permitted 
them to follow recent studies, are but imperfectly 
equipped for this exacting field of work. 

Treatment. — Before discussing medicinal and 
dietetic treatment let us briefly consider such general 
measures as are agreed on by all. First comes removal 
to a purer atmosphere; it is not so important that 
the temperature should be low as that the infant 
should be taken from surroundings that often are 
positively fetid. We have just noted some means of 
accomplishing this in discussing prophylaxis. Best 
of all is the floating hospital, first adopted in Boston 
and New York, where fresh air and clean food are 
added to expert medical attention; I wish to emphasize 
the last, as without it the excellent results achieved 
by these institutions would be lacking. In the same 
class I would place the seaside hospitals, now becoming 
quite numerous; they have the additional advantage 
that the infant need not be returned at night to the 
noisome tenement, but unfortunately the much greater 
disadvantage that they are more expensive to main- 
tain, and of course very limited in capacity. Recre- 
ation piers, with attached milk-stations, under medical 
control, fill the great gap that is left open by the 



INFECTIOUS DISORDERS 259 

aforesaid facilities; they are capable of as much ex- 
tension, as there is waterfront, and inexpensive of 
maintenance, after the somewhat heavy cost of con- 
struction has been covered. There are now ten of 
these recreation piers, distributed along the edge of 
Manhattan Island, and providing for at least as many 
thousands of babies. 

Local treatment of the intestine is of limited value, 
chiefly because the affected portion is practically 
inaccessible. Lavage is useful if vomiting is a promi- 
nent symptom (Lucas 2 ), but this usually ceases 
promptly when a suitable diet is adopted. The value 
of colonic irrigation has been overrated; it is of 
greatest use in those cases that pass on to a chronic 
colitis (Rotch 3 ). Medicinal treatment has com- 
paratively limited applicability. Many authorities 
initiate treatment with a purge; for this purpose 
calomel, in doses of -^V to y 1 -^ grain, frequently repeated, 
was once the universal drug; it is, however, no better 
than castor oil, and far more irritating (Abt), a point 
worth considering in the case of an already inflamed 
intestine. Castor oil may be of use in cases on the 
borderline, where fermentation still seems to predomi- 
nate over infection; I think it unnecessary, and even 
contra-indicated when the evacuations are watery and 
excessively frequent. 

In very severe cases, opium, though largely dis- 
credited in recent years, is still, in my opinion, the 
most valuable drug; if given in a dosage of 1 minim 
of paregoric to each kilogram (2 pounds) of the 
infant's weight, and carefully watched, it is of the 



2G0 DISORDERS OF DIGESTION 

greatest possible value and cannot do harm. Alcohol 
given in the form of 10 to 20 drops of whisky, diluted 
with ten times as much water, has also fallen into 
unmerited disfavor; in threatening collapse it is almost 
indispensable. In emergency such drugs as caffein 
and camphor are called for; I prefer the latter 
as more rapid in action, and give at least J grain, i. e., 
5 minims of a 5 per cent, solution in olive oil, hypo- 
dermically in fairly frequent doses. Caffein-sodium 
benzoate may be given in similar dosage, alternating 
with the camphor, until the infant has been tided over 
its collapse. 

For the intestinal condition, bismuth has always 
been a popular remedy, but its results are often disap- 
pointing; as it is merely astringent, and has no effect 
on the bacterial growth, it is not remarkable that it 
should frequently fail to be of benefit. In the later 
stages, when colitis is the most prominent feature, 
bismuth is more likely to prove useful, but I have 
had greater success with tannin, especially if given 
as an albuminate, such as tannalbin. 

To compensate for the great loss of body fluids, 
we often have to resort to saline infusions or the 
Murphy drip. We must take care to use a solution 
that is strictly isotonic (physiological), otherwise we 
run the risk of adding the complication of salt-fever, 
previously referred to. 

Serotherapy has turned out to be of little use. The 
favorable reports of Rudnik and Auche and Campana, 
as well as of some American authors, date from the 
early experimental period. At the same time we 



INFECTIOUS DISORDERS 201 

obtained adverse reports from La Fetra and Howland, 
Hastings, and Knox, which have not been refuted by 
subsequent experiences. There is at present no good 
prospect of an efficient specific therapy. 

Our main reliance in the treatment of infectious 
diarrhea is on dietetic measures. It was long ago 
recognized that treatment by prolonged starvation 
was likely to hasten the fatal outcome, and in the 
days when the true etiology of summer diarrhea was 
still unknown many of us learned to go over to albumen- 
water, after a starvation period not exceeding twenty- 
four hours. The preparation of albumen-water has 
been described on page 177. If made up with barley- 
water it contains about 1.5 per cent, each of proteins 
and carbohydrates, with practically no fat. In the 
light of our present knowledge it is not remarkable 
that a certain measure of success attended this mode 
of treatment; we must remember that in those days 
egg-albumen was considered safer than the dreaded 
casein of cow's milk. 

It has long been recognized that two dangers must 
be avoided in the feeding of these cases. Coolidge 
has contributed an article on the starvation method 
which sheds much light on one error in treatment; 
one of the worst things we can do is to give water or 
even barley water freely until the stools are approxi- 
mately normal; under this treatment the patient is 
likely to do badly. The next point is noted by Potter 
and others, and is in accord with much old and all 
modern practice, namely, to start in with a fairly 
ample protein diet within one or two days. There 



262 DISORDERS OF DIGESTION 

is at present little disagreement on this question, 
but Lucas 2 not so long ago still recommended a rather 
long period of preliminary starvation, followed by 
a very weak formula, which he made very low in fats. 
We have learned that the fats need not be kept so 
very low, and that we may safely give one-half to 
two-thirds of the normal percentage, provided we 
keep down the carbohydrates. 

Dunn 3 and Clock recommend the feeding of living 
lactic acid bacilli in a fat-free milk, but Dunn, 4 in a 
later communication, admits that this procedure has 
not been very effective. Dunn, 3 Decherf, as well as 
others recommend buttermilk. Whereas buttermilk 
and skim milk have, to balance their defects, at least 
an adequate protein content, this is not the case with 
whey, which has also been extensively given in summer 
diarrhea. We know that whey is essentially a lactose 
solution, with minimal amounts of both proteins and 
fats. Leopold and Muller offer evidence to show that 
whey rather favors intoxication in this condition 
instead of relieving it; we shall see that its adminis- 
tration is diametrically opposed to modern views, and 
based on a fundamental error. 

To Finkelstein 5 belongs the credit of first observing 
that the carbohydrates are the food element that 
causes the symptoms of intoxication in the severest 
forms of intestinal disturbance, and that withdrawal 
of sugar brings about a cessation of the fever, whereas 
a return to that food inaugurates a renewed rise of 
temperature. A really good explanation of this pheno- 
menon has hitherto been lacking, and the search for 



INFECTIOUS DISORDERS 203 

one led to the study of salt-fever as a possible factor; 
we have seen that this investigation has led to little 
of value so far as the main proposition is concerned. 
I would suggest a simple way of accounting for the 
pyrogenic action of sugar in intestinal infection, 
namely, that the growth of the bacteria requires a 
certain supply of carbohydrates, and that a medium 
poor in sugar checks their development. This would 
explain why sugar causes no trouble in the absence 
of these germs, even when the digestion of the fats 
is greatly impaired. As to the moderate intolerance 
for sugar that is witnessed in milk-atrophy, there is 
one very considerable difference to be noted, namely, 
that the sugar does not appear to act as a toxic sub- 
stance, and especially causes no rise in the temperature, 
which is indeed apt to be subnormal. The so-called 
intoxication-fever is best regarded as entirely due to 
bacterial toxins, and only to be indirectly referred to 
the sugar itself, insofar as it favors bacterial growth. 

Though Finkelstein seems to have missed the true 
significance of the intoxication-fever, he nevertheless, 
through careful clinical observation, evolved a method 
of feeding, unquestionably superior to any previously 
known; by working along entirely new lines, he 
devised the modification called albumin-milk, the pre- 
paration of which has been given in detail on page 118. 

Before going further, we must make note of certain 
precautions in feeding with albumin-milk. In the 
first place the milk must be prepared strictly accord- 
ing to specifications, particularly avoiding lumpiness 
(Finkelstein and Meyer 2 ); there have been a number 



264 DISORDERS OF DIGESTION 

of recent endeavors to prepare this food, by adding 
commercial casein to buttermilk, but the resulting 
product is not Finkelstein's albumin-milk, being 
nearly fat-free, aside from the uncertain food value 
of the desiccated casein. 

Some authors give albumin-milk too liberally; 
the limit should be six or seven ounces per kilogram 
of weight, or three ounces per pound, a very ample 
allowance, by the way, and too much for severe cases 
to begin with. Some add too little buttermilk; Finkel- 
stein 7 insists on the proportion of one-half; in the 
same communication he admits that the fat-ratio 
varies between 2 and 3 per cent. The latter figure 
is rather high, but may be avoided by using a rather 
low fat (3.5 per cent.) milk, as raw material for the 
curd extraction. Following this idea further a number 
of American pediatrists advise the preparation of 
albumin-milk from skim milk, instead of whole milk, 
thereby lowering the fats to a minimum; it is doubtful 
if this is ever necessary or even useful; at any rate it 
cannot be kept up for any length of time, for there 
is great danger, on so low a diet, of the continuance 
of the rapid loss of weight, which of itself constitutes 
a serious menace to the baby's life. 

Treatment with albumin-milk must not be delayed 
until the infant is moribund, but begun as early as 
intoxication appears, allowing a preliminary starva- 
tion period of twenty-four hours. In severe cases we 
may begin with a teaspoonful every two hours, say 2 
ounces for the first day, and add a similar quantity 
daily, until the limit is reached. Improvement sets 



INFECTIOUS DISORDERS 265 

in promptly in about three-fourths of all cases; 
in the worst ones, where we must, as before stated, 
begin feeding with small quantities, progress is slow 
at first, but in any event we may expect the fall in 
weight to come to a sudden halt, to be presently 
followed by a slow gain. This gain, however, is partly 
due to water retention to make up for the severe water 
loss from the diarrhea; a real growth cannot be 
expected from albumin-milk alone, with its low caloric 
value. At the same time the fever rapidly abates, 
the stools speedily improve, gradually assuming the 
soapy quality characteristic of merely disturbed 
nutritional equilibrium. 

As soon as the fever has gone down carbohydrates 
should gradually be added, 1 per cent, at a time. 
Birk 6 was one of the first to insist on this; it should 
be done with caution, using the temperature, stools, 
and weight as guides. The temperature must remain 
at least nearly normal, the stools must not be diarrheal 
or badly digested, and the weight must show a ten- 
dency to be stationary, after the slight early gain, 
which has been shown to consist of water (Stolte 1 ). As 
soon as the baby has been brought back to its original 
condition of disturbed equilibrium the albumin-milk 
should be abandoned in favor of one of the regular 
formula mixtures (Finkelstein and Meyer, 2 Stolte 1 ) . As 
to the carbohydrate to be added, the general consensus 
of opinion is in favor of malt rather than lactose or 
cane-sugar. In my own experience, albumin-milk plus 
malt has been a very satisfactory food for as long as 
six weeks, being given up chiefly because it was no 
longer necessary and troublesome to prepare. 



266 DISORDERS OF DIGESTION 

The earliest American experiences with albumin- 
milk were not brilliant; Heiman 2 and Morse, 4 while 
admitting that it might have a considerable field of 
usefulness, asked for more time and further trials 
before committing themselves in its favor. Finkel- 
stein, 7 however, and I think with some justice, criticises 
Morse's report as based on an incorrect administration 
of this food. Grulee 2 at once praised it enthusiastically, 
stating that he had given it continuously for months, 
by no means withdrawing it after a few w T eeks, as 
originally recommended. Friedlander and Green- 
baum also had excellent results; they too kept it up 
for long periods, gradually running up the total sugar 
to 7 per cent. These reports agree fully with my own 
moderately extensive experience. I may mention 
that American reports are steadily growing more 
favorable, and that only a few foreign authors, like 
Cassel, are lukewarm, whereas a few French authors, 
e. g., Weill and Mouriquond, are almost alone in con- 
sidering albumin-milk an utter failure. 

Recently, Morse 9 has observed that in cases of 
gas-bacillus infection malt is not so well tolerated 
as milk-sugar, being more readily fermented by this 
microorganism. It is quite possible that an accurate 
bacteriological diagnosis of the various types of infec- 
tion may lead to a greater refinement in therapeutics, 
and Vincent makes a strong plea in this direction. 
It is, however, clear that, for the present, such methods 
are not within reach of the ordinary practitioner, 
who will still have to be guided by the symptomatology 
in treating his cases of infectious 'intestinal disease. 



CHAPTER XT. 
DISORDERS OF METABOLISM. 

The disturbances of metabolism that are more or 
less in relation to infant feeding are quite numerous. 
They are mostly associated with artificial feeding, 
but may, under exceptional conditions, appear in 
nurslings; some few may be congenital, and in that 
event are more troublesome when the infants are 
bottle-fed. It is necessary for the practitioner to 
become intimately acquainted with these affections, 
as they are exceedingly common and must be reckoned 
with continually. 

THE EXUDATIVE DIATHESIS. 

Scrofulosis. — In the older works that deal with the 
diseases of children a great deal of space is devoted 
to the condition called scrofulosis. By scrofulosis 
was meant a diathesis characterized by enlargement 
of the lymph nodes and a chronic catarrhal condition 
of the mucous membranes, with a marked tendency to 
diseases of the skin, bones, and joints. The extremely 
chronic manifestations just referred to had a tendency 
to become acute or subacute from the most trivial 
causes, only to return, in the course of time, to their 
habitual state of a sluggish inflammation. 

With the discovery of the tubercle bacillus a vast 



268 DISORDERS OF METABOLISM 

amount of light was shed on the subject of scrofulosis. 
It soon was definitely ascertained that some scrofulous 
children were really tuberculous; not long after it was 
quite as clearly proved that others were not tuber- 
culous. Thus, Cornet was enabled to classify all cases 
of scrofulosis as follows: 

1. Tuberculous, caused by the tubercle bacillus. 

2. Pyogenic, caused by pyogenic bacteria. 

3. Mixed pyogenic and tuberculous infections. 
For all practical purposes the first and third groups 

may be thrown together, leaving the second for 
further consideration. These last children presented 
somewhat of a pathological puzzle; they exhibited a 
constant liability to catarrhal inflammations, without 
any discoverable underlying cause, which gradually 
led to the chronic enlargement of one or more groups 
of lymph nodes, especially those of the faucial ring. 
Sometimes these children were described as affected 
with lymphatism, an unfortunate term that has been 
used to include a large number of conditions that 
may or may not be related. 

About ten years ago a paper appeared, one of a 
series by Czerny, 2 in which he stated that these non- 
tuberculous, scrofulous children were the victims of 
a congenital and constitutional peculiarity which he 
called the exudative diathesis. The name was well 
chosen, as the most evident manifestation of this 
condition is a tendency to exudative inflammation 
of the skin as well as of the mucous membranes, the 
repetition of which results in the hypertrophy of the 
nearest lymph nodes. 



THE EXUDATIVE DIATHESIS 269 

Symptoms. — Czerny 2 describes the earliest stages of the 
exudative diathesis as follows: "Our suspicions should 
be aroused when apparently robust, but often more or 
less neurotic parents have a baby that seems puny and 
delicate; the first sign of trouble is failure to gain in 
weight even if supplied with breast-milk. The infant 
behaves almost as badly as if it were artificially 
nourished, even the human milk-fats being absorbed 
with some difficulty. The attending physician is very 
apt to accuse the maternal milk-supply of being at 
fault; we have, however, learned that a normal baby 
will do fairly well on rather inferior breast-milk, and it 
is important to bear this in mind when we have one 
of these cases before us. As a matter of fact the 
doubting attendant will promptly be undeceived if he 
resorts to a wet-nurse or to bottle-feeding; the former 
will do no good whatever and the latter will imme- 
diately lead to serious intestinal disturbance. Thus, 
feeding at the supposedly inferior maternal fount 
becomes imperative. As the infant grows older con- 
ditions improve a little, but the baby still lags behind 
the weight that is normal for its age; meanwhile, 
although there may have been no serious digestive 
disturbances, there is occasional feverishness, some 
anemia, a gradual or even rather rapid glandular 
enlargement, and often a tendency to develop eczema, 
all of which disorders are due to a feeble resisting 
power to mild infectious processes. Some of these 
infants are set back by frequent colds in the form 
of coryza, tonsillitis, or bronchitis; others manifest 
attacks of digestive disturbance; still others suffer 



270 DISORDERS OF METABOLISM 

from a catarrhal condition of the genito-urinary 
mucous membrane, with a liability to cystitis and 
pyelocystitis (Lust, 5 Beck 2 ); not a few are afflicted 
with several of these lesions. Most of the cases of 
infantile adenoids and tonsillar hypertrophy belong 
to this group." 

Treatment. — It will be seen that it is necessary to 
keep these infants at the breast, at all hazards, and 
at that we must be careful about overfeeding. Any 
attempt to fatten these babies is not only useless 
but positively harmful; the four-hour nursing interval 
must be adhered to strictly. Even if we do succeed 
in adding a few pounds of weight, not very much 
is gained thereby, as fat infants who suffer from the 
exudative diathesis are just as much subject to com- 
plications as those of subnormal weight. 

Artificial feeding of these infants is beset with the 
greatest difficulties, as the fat-digestion is exceptionally 
poor. Only low fat mixtures are tolerated at all, but 
even so, soap stools and obstinate constipation are 
the rule, and the replacement of milk-sugar with 
dextrin-maltose is usually necessary. In many cases 
bottle-feeding works out so badly that wet-nursing 
becomes imperative unless we wish to imperil the baby's 
life. Even the physiological process of dentition leads 
to irritability and functional disturbance; these are the 
babies that have created the popular apprehension of 
the dangers of teething, which never causes real illness 
in a normal infant. When the time for weaning arrives 
this transition is effected with difficulty, as by this time 
the baby is likely to have acquired some degree of 



THE EXUDATIVE DIATHESIS 271 

rickets and lymphatism; there is no little danger of a 
general breakdown at this period, and sometimes we 
encounter acute collapse and fatal heart-failure. 

Shortly after Czerny proposed this clinical entity 
numerous objections were raised; it was declared that 
he had merely been describing lymphatism under a 
new name. In a later paper Czerny 4 answers this 
criticism by explaining that the exudative diathesis is a 
congenital predisposition to infection, whereas lymph- 
atism is an acquired condition, often, to be sure, 
the result of the former disease. He improves the 
opportunity to go more fully into the subject of over- 
feeding, so widely practised in bringing up infants, 
either naturally or artificially. He points out that 
whereas some babies lay on fat easily, if they are 
overfed, and seem none the worse for it, others simply 
cannot be fattened. For this peculiarity the following 
reasons may be held accountable: either the child is 
partaking of an hereditary tendency to leanness, in 
which case it will be doing quite well in every other 
respect, or it will not gain because of poor absorptive 
faculties, in which case it belongs to the class here 
under discussion. 

Czerny's views have not yet gained general accep- 
tance, but have a great deal in their favor. They offer 
the only explanation, hitherto afforded, for those 
children that will not thrive on any sort of feeding, 
including the breast, and account for the development 
of many cases of rickets and lymphatism in breast- 
fed babies who have been brought up under the best 
hygienic conditions. Much of the objection is directed 



272 DISORDERS OF METABOLISM 

at the term chosen by Czerny; this point is hardly 
worthy of discussion; future observations will finally 
decide if the exudative diathesis is to be regarded as 
a clinical entity. 

ANEMIA. 

We have seen that the supply of iron is scarcely 
adequate even in human milk; many breast-fed 
babies, who are otherwise doing fairly well, have a 
hemoglobin index of barely 80. In artificial feeding 
matters are worse, for cow's milk contains relatively 
little iron, and the absorption of that metal, going 
hand in hand with the deficient absorption of calcium, 
is hardly ever equal to the baby's requirements; an 
index below 70 or even 60 is therefore not uncommon 
in bottle-fed infants. 

It is characteristic of infantile anemias that they 
take on severe and apparently even pernicious forms 
on occasions that, in later childhood, produce much 
milder manifestations. Morse 5 has shown that the 
type first described by v. Jaksch as anemia pseudo- 
leuksemica infantum, with marked lymphocytosis, 
myelocytosis, splenic enlargement, nucleated and 
degenerated red blood cells, and an extremely low 
hemoglobin content, is nothing but the severe phases 
of the ordinary secondary anemias at that age. Koplik 4 
has shown that v. Jaksch's anemia is not infrequently 
of intestinal origin; he reports a number of cases 
in infants suffering merely from a prolonged condition 
of disturbed equilibrium, which we know to be charac- 



ANEMIA 273 

terized by specially poor assimilation of calcium and 
iron. Finkelstein 8 gives an instructive review of this 
subject, stating that the regular cause of infantile 
anemia is an insufficient absorption of iron from the 
food. 

Treatment. — Finkelstein's plan of treatment consists 
chiefly in dietetic measures; he gives cereals, purees 
of vegetables that contain much iron, such as spinach 
and carrots, and also fruit juices. By way of medi- 
cation he gives iron and occasionally minute doses of 
arsenic. Of the iron preparations he rightly considers 
the inorganic preparations quite as useful as the modern 
proprietary organic compounds; my personal preference 
is for the syrup of the iodid of iron, in doses of 5 to 
10 drops, t. i. d., in sweetened water. Finkelstein 
also considers the climatic treatment of infantile 
anemia, and does not agree with those who recommend 
high altitudes; he prefers slight elevations up to about 
1200 feet, for dwellers near the sea-level. It should 
be remembered that the rarefaction of the air, at the 
elevation of a mile, as for example at Denver, Colorado, 
at once creates a requirement of an additional 30 per 
cent, of red blood cells and hemoglobin, thus imposing 
an extra strain on an organism that is already deficient 
in both these elements. I have gone into this matter 
quite fully in another place, 3 and at this point shall 
merely state my entire agreement with Finkelstein's 
conclusion. 

It is, of course, understood that, whenever possible, 
the anemia of infants should be treated by removing 
the cause, that is, by correcting any palpable errors 
18 



274 DISORDERS OF METABOLISM 

in the diet. A general examination is likely to reveal 
other physical deficiencies, particularly rickets, of 
which the anemia is often merely one symptom. 

ACIDOSIS. 

By acidosis we understand an abnormal form 
of metabolism, of a very obscure nature, which 
results in the formation of certain low fatty acids, 
particularly /3-oxybutyric acid, and manifests itself 
most obviously by the appearance of diacetic acid and 
acetone in the urine, as well as by certain constitutional 
symptoms of intoxication. The normal alkalinity of 
the tissues is diminished, and the ammonia that 
should neutralize the mentioned acids is eliminated 
as such. The classical picture of acidosis as it occurs 
in patients suffering from diabetes mellitus is clearly 
delineated by Naunyn as well as Chittenden and 
Mendel. Acidosis occurs also under other conditions, 
though usually in a less severe degree, and is not 
uncommon in young children and even infants. Its 
etiology in early life is not altogether unrelated to 
its causation in diabetes, so that we may safely refer 
to the authorities just mentioned in studying this 
metabolic error as found in infancy. 

Acidosis occurs, when the organism is not assimilating 
a sufficient amount of carbohydrates or fats, either 
through a pathological inability to utilize them, after 
absorption, as in diabetes mellitus, or because of an 
insufficient intake. As is well known, both causes 
often work together in the deadly form of acidosis 



ACIDOSIS 275 

occurring in diabetics. In childhood it has generally 
been rather hastily assumed that acid intoxication 
is due to overfeeding with carbohydrates; the greater 
probability that carbohydrate starvation is the cause 
has hardly been regarded seriously. Either cause, as 
well as fat starvation, may be operative in producing 
this condition in infancy. 

When too little carbohydrate and fat is assimilated 
from either cause, the body fats, secondarily the pro- 
teins also, begin to be disintegrated, not as normally, 
chiefly into water and carbon dioxid, nor in normal 
amount, but largely into intermediate bodies of the 
fatty-acid group and in great quantity. Meanwhile, 
as stated, the ammonia that should neutralize these 
acids fails to do so for reasons hitherto obscure. The 
pathological effects of the acids are still in doubt; 
we cannot, for the present, say whether they are 
injurious because of the reduced alkalinity of the 
tissues, or if they are directly toxic; probably both 
aspects of this matter are of importance. 

As there is always some breaking down of the body 
fats, and as the neutralization by ammonia is not 
absolutely to be depended on, a slight and occasional 
excretion of acetone in the urine is hardly to be 
regarded as pathological, and may occur in normal 
infants (Baginsky 2 ). It is, however, rare under 
physiological conditions, and Schrack claims that it 
is never found in babies fed on a pure milk diet. Little 
of interest, from the stand-point of infant feeding, 
was added to our knowledge until, some years ago, 
Marfan 2 reported a series of cases in children in whom 



276 DISORDERS OF METABOLISM 

acetonuria was associated with recurrent or periodic 
vomiting. In this condition it was not a question of 
traces of acetone but of such large quantities as half 
a gram per liter. Soon after, Edsall published an 
account of a similar group of cases, and since then 
reports have been numerous, so that this clinical 
picture has become familiar to all of us. In 1905 
two interesting papers, giving a description of the 
same syndrome in infants, were published by Morse 6 
and Langstein and Meyer. In both it was shown 
that acidosis is not rare in infants who suffer from 
gastro-intestinal diseases, which is a much less frequent 
association in older children and adults. Furthermore, 
evidence was introduced to show that the acetonuria 
was due to carbohydrate starvation by itself or as 
part of a general starvation, and that alkali loss, 
through an excess of low fatty acids in the intestine, 
was a regular feature, so that acidosis was brought 
into close relation to our old enemy, the poor absorp- 
tion and assimilation of cow's milk. 

Since then comparatively little has been added to 
our knowledge of this condition. It is not particularly 
frequent in infants because the error of carbohydrate 
starvation is rarely committed at that age; most of 
the cases occur in relation to starch-atrophy, and here 
the course of events is somewhat different. In starch- 
atrophy (Mehlnahrschaden) we have two factors oper- 
ating: (1) a breaking down of the carbohydrate assimi- 
lation, from persistent overloading with largely unas- 
similable starch, reminding us of the conditions in 
diabetes; (2) the infant that is brought up on one of 



ACIDOSIS 277 

the starchy baby -foods is subjected to a persistent fat 
starvation which results in an excessive breaking down 
of the body fats, largely into substances of the acetone 
group. Frew notes the interesting circumstance that 
slight acidosis often occurs when a baby is transferred 
from the breast to the bottle, and attributes it to 
carbohydrate starvation; the probability is much 
stronger that the difficult process of learning to absorb 
the cow-milk fats and temporary fat starvation play 
at least an equal role. 

Treatment. — As in diabetics so in infants, we may 
treat acidosis along two very different lines; we may give 
alkalies or we may add carbohydrates and fat to the 
diet. As in diabetic acidosis, so here also the administra- 
tion of alkalies affords only symptomatic treatment, and 
in no wise affects the underlying cause. At that the 
fixed alkalies are not an exact substitute for the body 
ammonia, which should effect the neutralization of the 
acids, and, if given in sufficient quantity, they interfere 
seriously with the gastric functions. Sodium bicarbo- 
nate is the favorite alkali for this purpose, but is likely 
to do as much harm as good; we have seen the objec- 
tions to loading up the infant organism with an excess 
of sodium. Potassium bicarbonate, given in a dosage 
not exceeding three grams (45 grains) per day, to 
a ten-pound infant, would theoretically seem far 
preferable. 

It is more rational to seek the removal of the cause 
of acidosis, which may be accomplished by a com- 
bination of two measures. First, the sugar should 
be run up to the normal ratio of 7 per cent.; secondly, 



278 DISORDERS OF METABOLISM 

we must see that the other food constituents are 
presented in sufficient quantity, at the same time 
looking to adequate absorption of the fats; this last 
may be aided by giving malt, instead of milk sugar, 
if the stools furnish evidence of deficient fat digestion. 
In any case, acidosis, in infants, should be very amen- 
able to treatment, since it can occur only when the 
diet scheme is very faulty or deficient. 

THE METABOLIC DERMATOSES. 

Eczema. — A whole school of dermatologists main- 
tains that eczema is a cutaneous disease, pure and 
simple, and in no sense merely symptomatic of an 
internal disorder; this stand-point does not always 
hold good for adults, and is certainly not true for all 
children. In infants most, if not all, cases of eczema 
are in some relation to disturbed metabolism, and 
the circumstance, that we cannot always indicate the 
latter with precision, is uot sufficient to invalidate 
the general proposition. 

Eczema is especially common in infants that suffer 
from the exudative diathesis, in fact, this constitu- 
tional infirmity derives its name from the tendency 
to exudative inflammatory processes, of which eczema 
is one of the most conspicuous. Moro and Kolb have 
furnished an especially exhaustive study of eczema, 
in which some interesting points are elaborated. For 
some unknown reason, it is commoner in boys; the 
infants are usually bottle-fed and fat; they have, 
in addition to the eczema, a marked tendency to 



THE METABOLIC DERMATOSES 279 

urticaria, and are often affected with rickets and 
spasmophilia. The last point is not remarkable, in 
view of the predominance of artificial feeding. Moro 
and Kolb do not hesitate to say that the exudative 
diathesis, or in other words, the congenital tendency 
to eczema, is the most essential etiological factor, 
aided of course, in many instances, by external 
injurious influences, such as heat, cold, moisture, and 
irritating agencies of various sorts. Holt 1 is quite sure 
that high fat feeding is in part responsible; other 
authors accuse the whey salts, and recommend a whey- 
free food, such as albumin-milk plus sugar (Finkel- 
stein 9 ); Brack, however, succeeds quite well in 
eliminating whey as a factor. 

There is an old superstition, still prevalent, that 
the endeavor to cure infantile eczema is apt to lead 
to dangerous and even fatal consequences; the disease 
is popularly said to strike inward. It is a fact that 
eczematous babies sometimes die suddenly, from no 
discoverable cause; such cases, as the one reported 
by Hichens, in which sudden death promptly followed 
a cure of the eczema, are not calculated to reassure 
the lay mind, though similar fatalities have been 
noted in unsuccessfully treated cases. Feer 2 has dis- 
cussed this matter very thoroughly. In medical 
circles, these deaths have been generally attributed, 
rather vaguely, to the condition called lymphatism; 
it is more accurate to regard them as due to spasmo- 
philia, which is not rarely fatal, and is a common 
complication of the exudative diathesis. Careful 
study of the case reports shows that the cure or 



280 DISORDERS OF METABOLISM 

continuance of the dermatosis has nothing to do with 
these so-called eczema-deaths. 

Treatment. — As to the treatment of these cases, 
aside from local applications, which are always neces- 
sary, and sometimes successful by themselves, we can 
say little that is definite. Our dietetic treatment of 
infantile eczema is unsatisfactory, and decidedly 
empirical, because we cannot always lay our fingers 
on the dietetic error present in the individual case. 
In addition, we are confronted with the far from 
easy task of combating the exudative diathesis, the 
cause of the frequent chronicity of this affection, so 
that the problem becomes doubly difficult. 

Nevertheless, we can take certain dietetic precau- 
tions, which may help us to our goal. The fats should, 
at any rate, be kept within reasonable limits, and 
we can easily avoid an excess in carbohydrates and 
salts, but more definite recommendations, as to other 
modifications, cannot be given. Each case must be 
considered separately, and some cases resist all dietetic 
treatment indefinitely, finally being cured by local 
measures alone. 

Finkelstein 10 warns us against a routine starvation 
treatment of infantile eczema ; this is indicated only in 
cases of obvious overfeeding, and usually modification 
is more desirable than a general reduction of the food 
allowance. 

Urticaria. — Urticaria is the metabolic dermatosis 
par excellence; it is very common and obstinate in 
infancy, occurring either in the typical form of 
wheals, or in the papular form, called strophulus or 



THE METABOLIC DERMATOSES 2S1 

lichen urticatus. In many cases, but not so often in 
this country, it represents the early stage of the 
constitutional affection known as prurigo. Before 
making the diagnosis of endogenous urticaria, the 
practitioner must first assure himself, in the individual 
case, that biting insects have nothing to do with the 
eruption; many cases of supposed urticaria are due 
to bugs, mosquitoes and the like. 

Recent studies on anaphylaxis seem to demonstrate 
that the ingestion of certain foreign proteins is the 
cause of urticaria, though other factors may some- 
times be responsible. According to this theory, the 
proteins of human milk should never cause urticaria, 
cow-milk proteins only under exceptional conditions, 
and such altogether foreign bodies as eggs and vege- 
table proteins more frequently. The observed facts 
are in accord with this hypothesis, to a certain extent, 
but many points cannot as yet be considered proved. 
As to the toxicity of egg-albumen for certain indivi- 
duals, and referring to observations in infants only, 
I merely cite the experiences of Baginsky and Bendix; 2 
O. M. Schloss has made a thorough study of the subject, 
and established the presence of an anaphylactic reaction 
for at least some cases. Among offending substances, 
other than eggs, may be mentioned almonds, oatmeal, 
besides several products of protein decomposition, such 
as the metabolic products of intestinal parasites, and 
certain substances formed in imperfectly preserved 
foods; the urticaria, that often follows the hypodermic 
injection of horse-serum, is familiar to all. 

As to the production of urticaria by bodies, other 



282 DISORDERS OF METABOLISM 

than proteins or protein derivatives, we cannot, for 
the present, speak positively, but all the available 
evidence is against it. 

Treatment. — The successful treatment of urticaria, 
especially in infants, has been hampered by our 
imperfect etiological information, and by difficulties 
in removing the cause. After we have eliminated such 
factors as insect bites and intestinal worms, we should 
direct our investigations to the ingested proteins; 
if cereals have been given, they should be stopped, 
oatmeal especially having recently become the object 
of considerable suspicion. Some authors suspect the 
whey-proteins of cow's milk as being more foreign 
than the casein; on this hypothesis we are justified 
in going over to sweetened albumin-milk. Now and 
then, we may encounter one of the cases of cow-milk 
idiosyncrasy, previously described; in that case, breast- 
feeding is the only remedy. 

Many authors, who have not convinced themselves 
of the anaphylactic nature of urticaria, hold the carbo- 
hydrates responsible; as to this, I can only repeat 
that this theory has not a shred of real evidence to 
sustain it. 

Preliminary to dietetic and medicinal measures, a 
brisk purgation with castor oil is the most rational 
treatment, for thus at least the intestinal tract is 
cleared of toxic substances. At the same time, we 
may treat the intense itching symptomatically, with 
soothing applications such as talcum and menthol. 
The alkalies have been widely recommended, largely 
on empirical grounds, for there is no evidence that 



THE METABOLIC DERMATOSES 283 

acidosis plays any role in urticaria. If we give lime- 
water, sodium bicarbonate, or sodium citrate, it should 
be in small doses, so as not to interfere with the gastric 
functions. Treatment with calcium salts, especially 
the lactate, has often been advised. The rationale 
of this procedure is far from clear, being based on the 
supposed relation of urticaria to certain hemorrhagic 
diseases. I have given this treatment a fair and 
quite extensive trial, and can state very positively 
that it has yielded me no results whatever. The 
best plan, so far as I can see, is to experiment with 
protein withdrawal, eliminating one possible offender 
after another, until we find that the cutting out of 
some one albuminous food causes cessation of the 
disease. 



CHAPTER XII. 

RICKETS AND SCURVY. 

RICKETS. 

Rickets is a chronic impairment of nutrition, 
formerly regarded as affecting chiefly the bones, 
but now recognized as implicating all the tissues of 
the body, including particularly the nervous system. 
It is exclusively a disorder of development, and there- 
fore peculiar to infancy and childhood, almost always 
beginning in the first year of life. 

Etiology. — The etiology of rickets is essentially 
dietetic. Other hygienic factors play an auxiliary 
and predisposing part, but the chief cause is artificial 
feeding. In our large cities, especially among negroes 
and Italians, moderate rickets may often be observed 
in breast-fed infants, but, generally speaking, the 
severe types of this affection are met with only in 
bottle-fed babies. The influence of bad general 
hygiene cannot, however, be ignored; Hansemann 1 
lays great stress on the lack of fresh air as a predis- 
posing factor, and considers the keeping of infants 
indoors as effective as unsuitable food in the production 
of rickets. These remarks are in accord with the 
racial observation just made; negroes and Italians 



RICKETS 285 

dread our severe winter climate, and do not take their 
babies out of doors in cold weather as freely as they 
should. I have been able to verify this statement in 
my dispensary service, where about one-tenth of the 
breast-fed infants present the symptoms of mild 
rickets; inquiry has shown that many of these babies 
have been kept home a great deal, the mothers not 
being able to spare the time to take them out into the 
air. Nevertheless the proportion of rickets is incal- 
culably greater among bottle-fed infants, nearly all 
of whom are at least slightly affected, even in well-to- 
do families, where the lack of fresh air is out of the 
question; it is also very common in bottle-fed country 
children. Furthermore, the severe forms are almost 
exclusively found among the artificially fed. The 
net result therefore is that bottle-feeding is the vastly 
predominating cause, which may indeed be aided by 
defective general hygiene, but is quite effective 
without it. 

To comprehend the dietetic causes of rickets we 
must go back to first principles. We have seen how 
poor the absorption of the fats of cow's milk is under 
the most favorable conditions and how the absorption 
of calcium and phosphorus suffers concurrently; 
we have also seen how much of the calcium goes to 
waste after absorption. The effect of this is most 
readily observed in the bones, the chief depositories 
of calcium and phosphorus; however, the nervous 
system also requires a large amount of phosphorus 
for its proper development, and a certain quantity 
is needed for the remaining tissues. The sum of 



286 RICKETS AND SCURVY 

these observations is that rickets is the manifestation 
of calcium and phosphorus starvation, caused by the 
imperfect absorption of the fats from cow's milk; we 
see at once why rickets is so much less likely to appear 
in breast-fed infants even under adverse hygienic 
conditions. 

It is important to remember that the ability of the 
bones and other tissues to take up calcium and phos- 
phorus is not in any way impaired; the trouble lies 
with the insufficient supply of these elements, and 
rickets has been caused in animals by simple depriva- 
tion of these substances. There is a definite minimum 
below which the tissues surfer from malnutrition; 
Aron estimates that the infant should add on 12 grams 
of lime for every kilogram of total gain in weight. 

Deficient fat absorption is by no means the only 
factor in producing rickets ; in the past the unwarranted 
fear of casein also played an important part. Since 
the food phosphorus is wholly or almost entirely 
derived from casein, it is quite evident that the 
development of rickets may be favored by protein 
starvation; this factor will probably become less 
influential with the abandonment of the fears as to 
the indigestibility of casein. I hope that the reader 
will not be troubled by the apparent paradox that 
low fat-feeding alone does not cause rickets even if 
carried out to an excessive degree; we have seen that 
when high fat ratios are given much of the fat is 
wasted; it is the waste fat that binds the calcium and 
renders it unavailable, but a shortage of fat has no 
effect on the calcium metabolism. Fat-starvation 



RICKETS 287 

may cause other disturbances, notably acid intoxication, 
but never rickets. 

Symptoms. — While rickets affects all the tissues of 
the body the most conspicuous lesions are in the 
bones, which present a condition that has been variously 
interpreted as chronic inflammation (Kassowitz 3 ) or 
chronic malnutrition. As is well known, the growth 
of bone takes place under the periosteum and at the 
epiphyseal lines. In rickets we find the latter swollen 
and hyperemic, with increased vascularization, finally 
leading to a marked palpable and even visible thickening 
of the ends of the long bones; at the same time there 
is a conspicuous deficiency in the deposition of true 
osseous tissue, because the necessary calcium and 
phosphorus are lacking. Pfaundler 3 declares the 
process to consist in the inhibition of the normal 
biochemical changes in the tissues, but this merely 
states a fact; it does not explain how the absence 
of calcium and phosphorus causes the local manifes- 
tations that are decidedly of an irritative type. The 
epiphyseal hyperemia must be either compensatory 
or due to the stimulus of a chemical body, possibly 
sodium chlorid, that is taking the place of the normal 
calcium and phosphorus. 

Concurrently with the lesion at the epiphyses the 
subperiosteal development of the bones is likewise 
impaired, and the cortex is also deficient in calcium 
phosphate, so that the shafts are much softer and more 
yielding than normal; the same is true of the cranial 
bones. 

The objective consequences of these defects are 



288 RICKETS AND SCURVY 

as follows. The long bones are thickened at their 
ends and their shafts bend easily, so as to be subject 
to permanent curvatures and green-stick fractures. 
The ribs are beaded at the junctions of the costal 
cartilages, forming the so-called rosary, and the ribs 
themselves are drawn inward by the traction of the 
diaphragm, causing the development of a groove along 
the insertion of that muscle (Harrison's groove) and a 
protrusion of the sternum (pigeon-breast). When the 
infant begins to stand up and walk, bow-legs, knock- 
knees, and flat-foot develop, The cranial bones are 
often so badly ossified as to bend like paper under the 
pressure of the finger (craniotabes) ; the closure of 
the fontanelles is much retarded, the head gradually 
assumes a squarish form, and occasionally becomes 
somewhat enlarged from a slight degree of hydro- 
cephalus, to be again referred to later. This enlarge- 
ment of the head persists as more or less marked 
and permanent bulging into later life. 

The pelvic bones sag as soon as the infant begins 
to sit up, and undergo a deformation that has serious 
consequences in females in the child-bearing period; 
this defect escapes notice in infancy, but is none the 
less to be borne in mind as a modifying factor in prog- 
nosis and as an indication to treat the disease early 
and thoroughly. 

These infants are late in sitting up, standing, and 
walking, not only because of weakness of the bones, 
but still more on account of their poor muscular 
development. The weakness of the dorsal muscles 
leads to the frequently observed pseudokyphosis that 



RICKETS 289 

is characteristic of rickets and must be carefully 
differentiated from the bony kyphosis of Pott's disease. 
The visceral unstriped muscles are also underdeveloped, 
so that the motor functions of the digestive tract 
are performed very inefficiently; there is a marked 
tendency to enteroptosis, and always more or less 
intractable constipation. The pot-belly that is so 
characteristic of rickets is due to relaxation of both 
the visceral and abdominal muscles. 

Rickets more or less affects all the internal organs. 
Enlargement of the spleen is almost constant, of the 
liver usual and of the lymph nodes very common. 
The visceral mucous membranes are somewhat hyper- 
emic and subject to catarrhal inflammation; there 
is, therefore, a considerable liability to bronchitis and 
enteritis, reminding one of the exudative diathesis. 
The subcutaneous fat may be normally and even 
excessively developed, as the carbohydrate assimilation 
is perfectly intact and likely to supply this demand 
quite adequately. The dentition is tardy and often 
irregular, and the teeth are apt to be ill-formed and 
excessively subject to caries. The blood always shows 
a fairly severe anemia, as the calcium and iron deficits 
go hand in hand. The nervous system is very deeply 
involved, presenting the condition that we shall con- 
sider later under the head of Spasmophilia. 

General sweating, often profuse, is characteristic 
of rickets; it is partly due to the general condition, 
for the nutrition of the skin is also impaired, though 
this is not demonstrable, and partly to the local bone 
hyperemias, being particularly intense about the 
19 



290 RICKETS AND SCURVY 

head, even in the absence of noticeable craniotabes, 
and also very marked about the epiphyses. The 
sweating of the scalp leads to restlessness, and the 
formation of a bald patch on the occiput, which is 
almost pathognomonic of rickets. The increased per- 
spiration is not associated with a rise of temperature. 

We must take care to remember that the lesions of 
rickets are so chronic as to be absolutely painless. 
Tenderness of thickened joints should lead the atten- 
dant to look for scurvy and not rickets. 

Diagnosis. — The diagnosis of rickets is usually ex- 
ceedingly easy; scurvy is the only affection that some- 
what resembles it, but scurvy is an acute disease, with 
extreme local tenderness as one of the cardinal symp- 
toms; what was formerly called acute rickets is now 
known to be scurvy. Occasionally the peculiar arrest 
in development called achondroplasia is designated 
as fetal rickets; it has nothing whatever to do with 
rickets, not being in any respect a disease of nutrition, 
but resulting from a dysplasia of the mesoblast in 
embryonic life. There has been considerable discus- 
sion as to the occurrence of true congenital rickets, 
with the preponderating evidence on the affirmative 
side; there is no doubt, however, of its extreme rarity 
in this country, and foreign authorities are gradually 
coming around to the opinion of Hansemann 2 that it 
must be exceedingly infrequent anywhere. 

The tendency of rachitic infants to inflammatory 
processes furnishes a point of contact with the exuda- 
tive diathesis, and it is highly probable that many 
reports of congenital rickets refer to the latter affection. 



RICKETS 291 

The lines of divergence are, however, numerous. 
Rickets is associated almost exclusively with artificial 
feeding, the bone symptoms occur in no other disease, 
there is no tendency to be subnormal in weight, and 
we often observe the nervous symptoms to be detailed 
presently. The exudative diathesis is congenital, 
persists in spite of breast-feeding and perfect hygiene, 
is almost always associated with a marked deficiency 
in weight, and entirely lacks the characteristic bone 
lesions of rickets. Of course, an infant suffering from 
the exudative diathesis may acquire rickets, and is 
pretty sure to do so if fed on cow's milk; in that case 
there will be no occasion for a differential diagnosis. 

Prognosis. — Since rachitic babies are very liable 
to inflammatory diseases of the mucous membranes, 
and are often affected by the dangerous nervous 
complications presently to be described, the prognosis 
as to life is seriously impaired as compared with normal 
infants. The prognosis as to duration is not at all 
good, for years are consumed in the functional compen- 
sation of the rachitic after-effects, which are always 
more or less permanent, and rickets of moderate 
severity never fails to pass on ineffaceable stigmata 
into adult life. 

Treatment. — All that the treatment of rickets can 
do is to arrest the progress of the disease. It goes 
without saying that a good general hygiene is essential. 
Fresh air comes first, because of its favorable influence 
on metabolism; the infant should spend most of the 
day out of doors except when it is actually raining; 
mere cold should be entirely disregarded. The bedroom 



292 RICKETS AND SCURVY 

should be well ventilated, and the employment of 
a hair pillow, instead of a feather pillow, tends to 
check sweating of the scalp, as moderate lightness of 
the bedclothes tends to check general sweating. A 
lukewarm bath should be given daily, followed by 
cool sponging; rachitic babies do not tolerate cold 
bathing, which should never be attempted. When 
the circumstances of the family permit, the infant 
should be taken into the country, as rickets is, to a 
very large extent, an urban disease. 

Breast-feeding, while not by itself an absolute pre- 
ventive, is nevertheless unfavorable to the develop- 
ment of rickets, and should be resorted to whenever 
possible; failing this recourse we must remedy any 
demonstrable errors in the scheme of artificial feeding. 
It is not only useless but positively harmful to run up 
the fat percentage; the fats are already poorly absorbed, 
and it is rather advisable to cut down this element 
in the food until the stools become approximately 
normal. On the other hand we can often benefit 
the infant by running up the casein as high as possible, 
for thus a good supply of available phosphorus is 
assured. From this we may readily conclude, that 
the most advantageous diet consists in a whole-milk 
mixture, in adding to the concentration of which we 
raise the protein ratio concurrently with the fats; 
we can increase the absorption of the latter by using 
malt instead of cane-sugar or lactose. Attentive 
observation of the stools is necessary, for soap stools 
show a heavy loss of calcium, which is inconsistent 
with improvement in the rachitic condition. Con- 



RICKETS 293 

stipation is always a troublesome feature, aggravated 
by its dependenee on two concurrent factors, namely, 
the fat-indigestion, and the poor muscular develop- 
ment of the intestine. One way of combating this 
symptom is through the substitution of oatmeal water 
for barley-water as the milk diluent; another consists 
in giving small doses of magnesium peroxid (milk of 
magnesia), but I have found this only moderately 
effective; in many cases we must be content to put 
up with a certain degree of constipation in the earlier 
period of treatment, relieving it with enemas or sup- 
positories when necessary. 

The medicinal treatment of rickets has undergone 
great vicissitudes. Setting out from the pathological 
basis of this disease we ought to secure improvement 
by giving phosphorus and calcium, but the effective 
administration of these substances is not so simple 
as it would seem; their absorption and assimilation 
are subject to certain biological limitations that are 
not, at first sight, obvious, but have been proved 
experimentally and must be reckoned with. Phos- 
phorus, given in doses of a fraction of a milligram 
in oily solution, was first recommended by Kassowitz, 1 
and seemed to produce fair but slow results, which 
were only tolerably satisfactory, though we now 
know that very rapid progress cannot be expected. 
Common white phosphorus is, moreover, a somewhat 
dangerous drug unless given with great caution; 
attempts were therefore made to substitute harmless 
phosphorus compounds as safer and perhaps equally 
absorbable and assimilable. These endeavors only 



294 RICKETS AND SCURVY 

served to discredit phosphorus therapy; the effects of 
the inorganic phosphorus compounds on rickets are 
very doubtful, though a few recent investigators assign 
some value to them; these doubts also apply to the 
vaunted glycerophosphates, as well as most of the mod- 
ern and complicated phosphorus preparations, which 
are quite as inert as the ordinary phosphates and 
hypophosphites. It is probable that the body can 
absorb phosphorus only as such or by splitting such 
organic phosphides as casein. 

Treatment with calcium salts has been tried exten- 
sively, and seems, at first sight, most rational; in 
practice, however, it is ineffective unless phosphorus 
is given at the same time, and even then its necessity 
is doubtful. Although the calcium waste appears to 
be the essential factor in producing rickets, it is 
better to control the loss of that element by giving 
phosphorus than to add lime-salts to a diet that 
already contains more than sufficient calcium. Schloss 
and Frank report increased retention of calcium and 
phosphorus from the administration of calcium phos- 
phate, but only if cod-liver oil is also given, so that the 
role of the former is more than doubtful. Schabad has 
shown that the administration of pure phosphorus in 
cod-liver oil triples the calcium assimilation in rickets, 
but is without effect in normal infants; he attributes 
much of the success to the oil, observing that cod-liver 
oil is a particularly absorbable fat which binds the 
calcium to a less degree than do the cow-milk fats; 
therefore by giving phosphorus in this fashion we 
both supply that element and favor the assimilation 



SPASMOPHILIA 295 

of calcium, more of which is left free to be deposited 
in the tissues of the body. 

From the above we may fairly conclude that any 
measure that promotes the absorption of fat is likely 
to give us the same result. The practice, now grow- 
ing very popular, of giving pure phosphorus in doses 
of about Y h) g ra i n (0-3 milligram) in malt-extract 
seems therefore perfectly sound, as malt also favors 
fat absorption, thus diminishing the calcium waste. 
Both cod-liver oil and malt as vehicles of phosphorus 
seem to hasten its curative action in rickets; both 
methods can easily be controlled in the individual 
case by watching the feces. If these tend to become 
normal and the constipation ceases we may be reason- 
ably certain that the progress of the disease has been 
arrested. 

If we have, provisionally, passed over the neurolo- 
gical manifestations of rickets it is because they have 
been generally treated as a distinct disease. A change 
in opinion is now in progress, but no harm will be done 
by discussing this group of lesions separately under the 
head of 

SPASMOPHILIA (TETANY). 

The terms spasmophilia and tetany are often em- 
ployed interchangeably, but are by no means synony- 
mous. Tetany is a condition of muscular spasticity 
(hypertony) that may arise from the most varying 
causes; it is one of the symptoms of a variety of 
conditions, including such diverse diseases as tetanus 
and strychnin poisoning. Spasmophilia is the better 



296 RICKETS A XT) SCURVY 

name for the condition before us, as it designates a 
diathesis characterized by a tendency to tetany which 
may, however, be latent or temporarily in abeyance. 

By infantile spasmophilia we designate a liability 
to tonic and clonic spasms of every kind occurring 
in early life; the field is thus evidently a wide one, 
including the most various clinical manifestations: 
(1) we recognize clonic convulsions of the eclamptic 
type, occurring without any evidence of intracranial, 
visceral, or acute febrile disease; (2) we note the 
tonic spasms or contractures that are characteristic 
of what is properly called tetany; as well as the 
cataleptic seizures described by Epstein; (3) there is 
the classical triad of symptoms: Chvostek's, consisting 
in reflex overexcitability in response to tapping of 
the muscles, best shown in the face; Trousseau's, 
consisting in tonic spasm of a slightly constricted 
extremity; Erb's, consisting in increased reaction to 
electric currents. Recently a number of other symp- 
toms have been assigned to spasmophilia. Escherich 3 
claimed that laryngospasm was a part of this clinical 
picture, and his view was only apparently contradicted, 
but really confirmed, by Kassowitz, 2 who considered 
this symptom a sign of rickets. Hochsinger furnished 
convincing evidence that at least a majority of the 
cases of infantile nystagmus and nodding spasm, 
which form a syndrome, belong to this group. Not 
without interest is a recent statement by Hess 5 in 
which certain cases of pylorospasm, cardiospasm, and 
pharyngospasm are regarded as phases of spasmophilia. 
Careful examination of a large number of infants has 



SPASMOPHILIA 297 

shown that there are many eases of latent spasmo- 
philia in which we can find only one or two symptoms 
of the Chvostek-Trousseau-Erb triad, without the 
presence of any of the severer manifestations; it is 
worthy of note that these infants are regularly rachitic. 

The very circumstance that we find rickets in prac- 
tically all the cases of spasmophilia would lead us to 
conclude that the latter is merely a manifestation of 
the former; for many years, however, exact proofs 
were lacking. At one time considerable doubt was 
cast on this relationship by the discovery that tetany 
was caused by removal, or disease of, the parathyreoid 
glands. Stoltzner, however, showed that, aside from 
the spastic symptoms, spasmophilia parathyreopriva 
and spasmophilia rachitica have very little in common; 
the latter presents neither tremor nor fibrillary twitch- 
ing nor tachycardia nor stupor; it is made worse by 
continued feeding with cow's milk, whereas the former 
is uninfluenced by the diet. Stoltzner errs, however, 
in considering spasmophilia a manifestation of calcium 
poisoning; we now know that rickets is the result 
of calcium-starvation, and Nothmann 3 has shown 
that the parathyreoid form of spasmophilia is also 
associated with a calcium deficit. This point forms 
indeed the one connecting link between these two 
affections; both are associated with a lack of calcium, 
but their ultimate causes are quite different, from the 
evidence now at hand. 

Schabad 3 shows that the metabolism of spasmophilia 
is identical with that of rickets; Cybulski has demon- 
strated that the spasms disappear as the calcium 



298 RICKETS AND SCURVY 

retention improves; finally, Curschmann reports two 
cases of fatal spasmophilia in which the parathyreoid 
bodies were found normal on autopsy. 

Symptoms. — The reader will recall that in the dis- 
cussion on starch-atrophy (Mehlnahrschaden) we noted 
muscular rigidity as a conspicuous symptom in the 
later stages; in other words, the infants affected 
with malnutrition from this cause exhibit signs of 
spasmophilia. Ackermann takes Czerny and Keller 
to task for attributing this condition to the ingestion 
of excessive amounts of starch, and so far is justified 
in his criticism. Nevertheless the clinical observa- 
tions of Czerny and Keller were quite correct insofar 
as hypertony of the muscles does occur as they des- 
cribe; the only real question involved is that of 
causation, and that is capable of explanation. The 
trouble with feeding on Nestle's food and the like is 
not only because of the excess of starch, but even 
more on account of the attendant protein starvation. 
Starch-atrophy is a complicated process in which 
carbohydrate intoxication plays at the most a ter- 
minal role, fat-starvation and acidosis are conspicuous, 
as we have seen, and rickets, including spasmophilia, 
an essential feature. Keller's treatment recognizes 
all these characteristics; it does not so much cut 
down the quantity of the carbohydrates as substitute 
more digestible ones; it gives some fat and renders 
it more assimilable by also giving malt; it further 
checks the calcium waste, through the addition of 
potassium carbonate, which distinctly favors calcium 
retention. Thus, Keller's methods are based on a 



SPASMOPHILIA 299 

correct clinical observation, and work toward the 
desired end, even though all our present biochemical 
data were not available a decade ago when this plan 
of feeding was devised. 

The observation of Lust 5 that potassium, given as 
a chlorid, is spasmogenic, cannot for the present be 
reconciled with the above; we do well, however, to 
recall that spasmophilia was regarded as due to 
calcium-poisoning by Stoltzner, whereas Lust's re- 
searches indicate that the administration of this 
element reduces the motor excitability. This question 
is evidently still unsettled. 

I think that I have presented sufficient evidence 
of the close interrelation of rickets and spasmophilia; 
such recent authors as Langstein 3 commit themselves 
unreservedly to this proposition. We shall probably 
not go far astray if we regard spasmophilia as the 
manifestation of rickets in the nervous system, and its 
cerebral symptoms as due to meningeal hyperemia in 
connection with cranial rachitis. This theory receives 
support from the presence of slight hydrocephalus 
in severe cases. It only remains for us to clear 
up some points of differential diagnosis. In the first 
place we must not confuse laryngospasm (laryngismus 
stridulus) with congenital laryngeal stridor; the former 
consists of a true spasmodic closure of the rima glottidis, 
lasting a minute or thereabouts, and ending in a deep 
sighing or crowing inspiration; congenital laryngeal 
stridor is more or less constant and does not occur 
in fits. The former is not congenital but begins between 
the third and twelfth months, the very period when 



300 RICKETS AND SCURVY 

the underlying disease, namely rickets, begins to show 
its characteristic development. General convulsions 
must also be subjected to a careful differentiation; 
the spasms of genuine spasmophilia are apt to occur 
without any demonstrable cause, whereas in other 
infants convulsions are either of distinctly cerebral 
origin or mark the beginning of a sharp rise of tempera- 
ture, corresponding to the chills of later life. The 
nystagmus must be distinguished from that due to 
labyrinthine disease; this is often exceedingly difficult, 
as the precise mechanism of spasmophilic nystagmus 
is still unsettled, the prevailing view being, that it 
is merely the consequence of weakness of the motor 
apparatus of the eye-ball; examination of the ears 
will naturally clear up many doubtful cases. I cannot 
subscribe to the proposition, made in some quarters, 
that a slight Chvostek phenomenon may be disre- 
garded if other spastic signs are wanting; it seems 
safer to keep in mind the picture described as latent 
spasmophilia, especially in view of the fact that prac- 
tically all of the infants thus affected present symptoms 
of typical rickets. 

Prognosis. — The prognosis of spasmophilia is very 
doubtful, as the general convulsions not uncommonly 
prove fatal; laryngospasm is also a threatening 
symptom, and the seriousness of an infection of these 
babies with respiratory disease or whooping cough 
is readily understood and can hardly be overestimated. 
^VYhooping cough alone is responsible for hundreds of 
deaths annually in the city of New York, and this mor- 
tality is chiefly among rachitic and spasmophilic infants. 



SPASMOPHILIA 301 

Treatment. — The treatment is that of the underlying 
rickets. Calcium salts have been tried extensively 
for the attacks themselves. Freudenberg and Kloc- 
mann observe that their action is prompt but only tem- 
porary; Bliihdorn gives calcium chlorid and bromid 
in daily doses of 2 or 3 grams, but claims only symp- 
tomatic value for his treatment ; Aschenheim gives 7 to 
10 grams daily of calcium lactate. The reason for the 
mere transitoriness of the action of calcium is the same 
as in the case of the ordinary symptoms of rickets; 
the calcium is not permanently assimilated. I must 
not fail to repeat that many authors consider cal- 
cium spasmogenic, so that this course of treatment 
still rests on an insecure foundation. Berend found 
magnesium salts valuable, again in opposition to the 
prevailing views, though the investigations of Meltzer 
and Auer have probably settled conclusively the 
usefulness of magnesium sulfate injections in the 
spasms of true tetanus. 

More satisfactory are the results obtained from the 
treatment of the underlying disease, which has 
already been discussed. The symptomatic treatment, 
described above, may be employed during the time 
that we are gradually correcting the general nutrition, 
which always takes some weeks, at least, before 
improvement is apparent. Spasmophilia is by far 
the / most serious manifestation of rickets, and the 
chief reason for energetic prophylactic measures 
against this disease, which, to a decided degree, is 
to be classed among the preventable disorders, its 
present marked prevalence not being creditable to 



302 RICKETS AND SCURVY 

modern pediatrics. On the other hand it cannot 
be denied that something has been accomplished in 
this direction; with the growing insistence on breast- 
feeding, the steadily improving methods of artificial 
feeding, and the general rise of hygienic standards 
it is certainly true that the worst forms of rickets 
are gradually disappearing from our hospitals, so 
that recent decades have shown some little progress. 

SCURVY. 

The occurrence of scurvy, in infants, was first 
suggested by Glisson, but its general recognition 
dates from an article by Moller, in which he dis- 
cussed what he called acute rickets. Jalland was 
the first modern writer to identify infantile scurvy, 
antedating the classical report of Barlow ten years. 
The general acceptance of this identification with 
the scurvy of adults dates from the closing years of 
the last century. 

Etiology. — As in adult, so in infantile scurvy, the 
precise etiology is still uncertain; we know that it 
follows in the wake of a diet consisting too exclu- 
sively of certain preserved foods, and conversely, 
that fresh and especially raw foodstuffs of various 
kinds absolutely prevent its development, besides 
affording a specific cure. On this subject the most 
comprehensive investigation has been made by the 
American Pediatric Society, of which a good summary 
is given by Griffith; it shows that the majority of 
infants who are affected by scurvy have been fed on 



SCURVY 303 

proprietary baby-foods, and that the employment of 
condensed and sterilized milk accounts for most of 
the remainder. The observation that a very few 
cases have been fed at the breast, or on raw cow's 
milk, must be interpreted as a diagnostic error; in 
view of our present knowledge of the subject such an 
occurrence is simply impossible. 

The most diverse foods have been, more or less 
justly, charged with causing this disease; I give a 
few by way of illustration: The role of the starchy 
baby-foods, especially of such as contain desiccated 
milk, is indisputable (Still); cereals in general favor 
its development (Hoist and Frolich), but Concetti 2 
claims that this is true only when spoiled grain is used. 
The bad effects of homogenized, superheated, con- 
densed, and desiccated milk have already been dis- 
cussed under those headings; I merely cite the 
reports of Bourdillon, Bernheim-Karrer, Esser, and 
Hart. As to ordinary sterilized milk, opinions are far 
from unanimous. Finkelstein 2 is sure that it never 
is the sole cause of scurvy; Neumann says that only 
prolonged and excessive sterilization can render milk 
injurious; Schulz thinks that trouble may arise from 
the trace of silica that goes into solution when sterili- 
zation is carried out in glass vessels, and Plantenga 
considers sterilized milk perfectly safe if it is not kept 
over twenty-four hours. In this connection I may 
repeat that I have repeatedly observed scurvy in 
the children of physicians who had seen to thorough 
surgical sterilization of their babies' food. As to the 
various modifications of milk, Combv credits Gartner's 



304 RICKETS AND SCURVY 

fat-milk with producing scurvy, and Keller's malt- 
soup has also been regarded with warranted suspicion, 
although, according to Garrod's theory, the addition 
of potassium carbonate should act as a preventive. 

Pasteurization is admittedly an imperfect method 
of sterilizing milk, and has only rarely been charged 
with producing this disease. 

As to the four current theories of scurvy I must 
refer to a contribution by Hutchinson, who gives 
them in full; they cannot possibly be harmonized, 
and some modification of Garrod's view, to the effect 
that it is due to the deprivation of some necessary 
food ingredient, is most likely to prevail in the end, 
for the test of treatment very decidedly points in that 
direction. 

Symptomatology and Diagnosis. — The following des- 
cription will deal only with the infantile form of this 
disease, for which Morse 7 has given a good outline 
of the symptomatology. The first sign is usually 
tenderness about the joints; next come gingivitis, 
and about the same time paresis (pseudoparalysis) 
of the extremities; later on we may witness hema- 
turia and edema, but severe hemorrhages are rare 
because the affection is usually recognized and treated 
before it reaches this stage. Still and Snow mention 
orbital hemorrhage, with retrobulbar hematoma and 
consequent exophthalmos. ^Ye may go on to a more 
detailed description of some of these symptoms. 
The tenderness of the joints is so great that the baby 
screams out loudly if it be ever so gently moved; 
this is so characteristic that the diagnosis may often 



SCURVY 305 

be made from this sign alone. Examination shows 
epiphyseal swelling, resembling that found in rickets; 
we cannot go astray if we remember that rickets 
is painless; what was formerly called acute rickets 
we now know to be scurvy. The frequently made 
diagnosis of rheumatism is quite unpardonable; arti- 
cular rheumatism is very rare in infancy, and nearly 
or quite painless at that age. The diagnosis from other 
forms of acute arthritis, as well as osteomyelitis, is 
more difficult, but these latter affections are usually 
attended with considerable fever. 

The inflamed gums are tender and swollen, bleeding 
at a slight touch ; the diagnosis from infectious or aphth- 
ous gingivitis can usually be made at a glance; in the 
latter the presence of pus or isolated white spots is char- 
acteristic, and the swelling and hemorrhage are much 
less conspicuous. Subcutaneous and visceral hemor- 
rhages occur so late in the disease that the symptoms, 
previously described, are sure to be present, otherwise 
the diagnosis from other forms, for instance, syphilitic 
hematuria, would be attended with some little diffi- 
culty. Should edema occur by itself it would of course 
be a very equivocal symptom; fortunately this is 
a most unlikely event. In my experience the diseases 
most resembling infantile scurvy, and most easily 
confounded with it, are infectious erythema (erythema 
multiforme) and the allied syndrome called Henoch's 
purpura, which may perhaps be due to an analogous 
nutritional disturbance, at least in some cases. Clini- 
cally, however, confusion rarely arises from these 
sources. 
20 



306 RICKETS AND SCURVY 

We are now in possession of an additional means 
of early diagnosis, namely, the .r-rays. The Rontgen 
rays show the epiphyseal lesions before the appearance 
of clinical symptoms (Rehn, Hoffmann). The charac- 
teristic feature of scurvy is a dark shadow on the 
epiphyseal line, whereas in rickets we see an intensi- 
fication of the normal light band at this site. 

Treatment. — The treatment of infantile scurvy is 
exceedingly simple. The juice of the citrus fruits 
(orange, grape-fruit, lime, lemon) has been the sovereign 
remedy for centuries in the case of adult scurvy, and 
its effects have been quite as brilliant in early life, 
so much so as to render other remedies all but useless. 
Nevertheless, I may mention other antiscorbutics, 
namely, beef -juice, cabbage and its botanical allies 
(cress, turnips, mustard), and potatoes; none of these 
is quite as suitable for infants as orange- juice, given 
in doses of 2 or 3 teaspoonfuls before each feeding. 
It is also advisable to change to an antiscorbutic 
diet, with a basis of raw or moderately pasteurized 
milk, but this is not indispensable if the fruit-juice 
is given regularly and is well tolerated. It must be 
admitted that the action of fruit-juice is still very far 
from clear, and Garrod's theory, even if modified so 
as to apply to the organic salts of potassium, affords 
no real explanation. As a matter of fact our know- 
ledge of scurvy has advanced but little since P wrote 
on the hemorrhagic diseases more than ten years ago, 
and our treatment is still actually quite empirical, 
though undoubtedly specific. 

Orange-juice is also valuable as a convenient and 



SCURVY 307 

trustworthy prophylactic. It often happens that we 

are compelled to feed an infant on sterilized milk; 
since the unavoidable dangers, that lurk in raw milk, 
have become increasingly emphasized it is most grati- 
fying to be enabled to give more or less sterilized 
food without incurring the risk of scurvy. This 
prophylactic treatment may be effectively accom- 
plished by giving the infant one or two teaspoonfuls 
of orange-juice twice a week, a quantity quite suffi- 
cient to serve as a preventive. I have been doing this 
for some years in cases where artificial feeding with 
boiled milk was necessary. In view of a recent ex- 
posure I feel justified in a slight distrust of even cer- 
tified milk, which I rarely give without preliminary 
heating, trusting to small doses of orange-juice to 
counteract any tendency to scurvy that may lurk 
in this imperfectly sterilized food. I never omit the 
orange-juice if I have occasion to resort to Keller's 
modification for any length of time, and have never 
seen scurvy arising under these conditions and pre- 
cautions. 



CHAPTER XIII. 
THE FEEDING OF OLDER INFANTS. 

Weaning. — Weaning, that is, removal from the 
breast, is physiological toward the end of the first 
year, but must sometimes be resorted to earlier, for 
various reasons. It is usually a perfectly safe proce- 
dure if the infant has attained the age of nine or ten 
months and has not presented any signs of the exuda- 
tive diathesis, for normal infants of that age usually 
tolerate cow's milk well and often seem to gain more 
rapidly than before weaning. An exception should, 
however, be made if the infant attains the stated age 
during the summer months; in that case it is wiser 
to postpone weaning until the autumn, so as to avoid 
the risk involved in feeding with milk of doubtful 
purity. 

Sometimes the supply of breast-milk begins to fail 
in the middle of the first year; when this happens we 
must, of course, go over to cow's milk, but we should 
always endeavor to interpolate a period of mixed 
feeding, giving the breast at eight-hour intervals, 
and two artificial feedings during the intermissions. 
In this manner, matters may often be tided over for 
several months until the normal weaning period. 

Even at the age of nine months it is a good plan 



WEANING 309 

to begin with mixed feeding, according to the above 
schedule, substituting the artificial food gradually, 
so as to extend the weaning period over a month if 
possible. Until the age of twelve months, as a general 
rule, the cow's milk should be diluted and sweetened 
by mixing eight ounces of barley water with thirty- 
two ounces of milk, adding an ounce of cane-sugar 
or milk-sugar, and dividing the whole into five eight- 
ounce portions. 

The practice of prolonged breast-feeding, until 
the age of fifteen and even eighteen months, is met 
with in certain classes of our population, and is said 
to be usual in Japan. In some cases the infants appear 
to thrive and gain in weight on this feeding, but inquiry 
will almost always show that other food is also being 
given. Breast-milk alone is an insufficient food after 
the twelfth month, the supply gradually becoming 
inferior in quality even if the quantity remains ample; 
this practice of prolonged lactation should therefore, 
as a rule, be discouraged. Occasionally in the case 
of very poorly developed infants an exception may be 
made, but this eventuality is particularly rare, because 
the children of mothers whose lactation continues 
into the second year are apt to be rather above the 
average in general condition. In many cases the 
retardation of the infant's growth is actually caused 
by the gradual decline in the mother's milk-supply, 
and some of these infants improve with astonishing 
rapidity immediately after weaning. 

Sometimes acute illness of the mother renders im- 
mediate weaning imperative; in this event we must 



310 THE FEEDING OF OLDER INFANTS 

begin cautiously with a formula suitable to a somewhat 
earlier age, as the infant's tolerance for cow's milk 
is an unknown quantity. The process sometimes 
becomes extremely difficult, presenting in fact the 
entire problem of artificial feeding. 

In weaning, the infant may at first refuse to take 
the rubber nipple; this may usually be overcome by 
a few hours of starvation, but some babies offer an 
obstinate resistance that can be overcome only by 
an exercise of the greatest patience. Equal diffi- 
culty is often afforded by the transition from the 
bottle to spoon feeding, but in these cases also the 
battle will usually be won by delaying or skipping a 
meal. Spoon-feeding should be begun before the 
fifteenth month, preferably about the turn of the 
year, because waiting longer is likely to make the 
change more difficult. The time-consuming labor of 
cleansing bottles and nipples should not be imposed 
upon the mother or nurse any longer than is necessary, 
and we can hardly begin the inculcation of proper 
habits of eating too early. 

More objectionable even than excessively prolonged 
lactation is too early feeding with substances other 
than milk. This harmful practice is almost the rule 
in some countries, for example, Germany, where 
early feeding with pap is a fertile source of digestive 
and nutritional disorder (starch-atrophy). Starch- 
feeding, save in the very small amounts given in weak 
cereal decoctions, is quite unsuited to infants under 
the age of six months, and is best withheld for three 
months longer. There is no harm in waiting until 



FEEDING DURING THE THIRD HALF-YEAR 311 

the end of the first year unless the ehild eeases to 
gain in weight on milk alone, and the perfect func- 
tionating of its digestive apparatus plainly shows that 
the trouble really lies with insufficiency of food. 
When this can be made out with certainty we may 
give a few ounces of well-cooked and strained cereal 
in milk, or an equal quantity of plain crackers, well 
broken up and soaked in milk, but no other kind of 
food should be added before the first year has elapsed. 

Feeding During the Third Half-year. — After the 
twelfth month we may take the first steps in the 
direction of a mixed diet. This is facilitated, if we 
limit the total amount of milk to one quart per day, 
so that the child will desire other food; if we give 
large quantities of milk, as is sometimes done, the 
child may be satisfied with this alone, which is undesir- 
able for two reasons. In the first place, milk has only 
one-fourth to one-half the caloric value of our common 
foods, there is therefore danger of insufficiency; 
secondly, it is not desirable to distend the stomach 
with unduly large quantities of fluid, which becomes 
inevitable if we try to feed an older infant on milk 
exclusively. 

The number of meals should now be reduced to 
four per day; the five meals recommended by most 
authors are inconsistent with a sufficient interval, 
which should remain fixed at nearly four hours; I 
have found the hours of 7.30 and 11 a.m. and 3 and 
6.30 p.m. the most convenient. Too frequent feeding 
is one of the causes of the anorexia that so often is 
a source of trouble and anxiety in very young children. 



312 THE FEEDING OF OLDER INFANTS 

We may begin by giving the child crackers and 
rusks (zwieback), if those articles have not already 
been added to the dietary, as well as a well-cooked 
cereal once a day. I prefer the old-fashioned cereals, 
rice, farina, hominy, and oatmeal to the modern fancy 
cereal foods, which leave too little undigested residue 
and are therefore apt to favor constipation; oatmeal 
should be strained at first, but this is not necessary 
with the other cereals mentioned. The cereals may 
be somewhat sweetened, but an excess of cane-sugar 
should be avoided; too much strictness in this regard, 
however, is not justified, for there is no doubt that 
most persons who are fond of sweets can assimilate 
relatively large amounts of sugar; the desire for 
sweet things often indicates a physiological demand. 
A portion of the daily milk-supply should be used 
in cooking the cereal. 

After a month or two we may add a soft-boiled or 
coddled egg to the daily dietary. Coddling consists 
in immersing the egg, for two or three minutes, in 
water that has been taken off the fire when the boil- 
ing-point has been reached; a coddled egg has a softer 
albumen than the ordinary boiled egg. Some authors 
recommend meat-juice at this period; we have seen 
that it contains very little nourishment, but the 
taste is usually relished, and a few teaspoonfuls can 
do no harm, and may act as an appetizer. Broths 
and soups are usually given at this age; plain meat 
broths are rather objectionable than otherwise, as 
they consist chiefly of a solution of salts and purin 
bodies; but cereal soups, such as rather thick rice 



FEEDING DURING THE FOURTH HALF-YEAR 313 

and barley broths, have some little food value. The 
total amount per day should not exeeed four ounces; 
the common practice of filling up young children 
with large quantities of soup impairs the appetite 
for more nutritious food and tends to overload the 
stomach. 

Feeding During the Fourth Half-year— At the age 
of eighteen months, sometimes a little sooner or later, 
according to the development of the child's dentition, 
we may increase the variety of the food. Many 
infants now no longer take their full quart of milk 
when other food is given; some parents regard this 
seriously, but it is not an important matter if ample 
other nourishment is taken. 

We may now begin to give scraped beef, chopped 
beef, and finely minced chicken, later on the finely 
cut inside of a lamb-chop; fat meats like pork and 
duck are unsuited to this age. Fresh fish is quite as 
good as fresh meat, and may be substituted for it 
once or twice weekly. There is a popular prejudice 
against giving meat before the age of two years, which 
has no physiological foundation whatever, for lean 
meat is one of the best means of giving the necessary 
protein, and should be included in one of the daily 
meals. Fat gravies, however, are absolutely pro- 
hibited. The egg ration may be continued, and the 
number may often be increased to two per day, one 
in the morning and one in the evening. 

The use of crackers, rusks, and cereals should be 
continued, the soup ration on no account increased. 
We may now begin with bread, provided it is not too 



814 THE FEEDING OF OLDER INFANTS 

fresh; a good plan is to reheat the bread of the pre- 
ceding day in the oven, or to toast it; it may be buttered 
to suit the child's taste. 

Fresh vegetables now are also in order, such as green 
peas, string beans, asparagus tips, spinach, carrots, 
and baked potatoes; all of these must be thoroughly 
mashed. There is no objection to stewed tomatoes 
if carefully strained. Fruits may also be given; in 
addition to the daily spoonful of orange-juice, apple- 
sauce and the pulp of stewed prunes are valuable 
means of regulating the bowels. 

Tea, coffee, and cocoa, often given to very young 
children, are all very objectionable, and it should 
hardly be necessary to mention that alcohol in any 
form is a dangerous poison. At this age it becomes 
important to guard the child against the formation 
of the candy habit, which is often encouraged by 
thoughtless visitors and admirers. Before the age of 
two years the smallest amounts of candy or chocolate 
should be strictly banned. 

We can now go over to the regular three meals 
per day, giving milk and crackers in the afternoon, 
to aid in spanning the long interval between luncheon 
and supper. A practical schedule is somewhat as 
follows : 

8 a.m. One ounce of orange-juice. 

Two ounces of cereal, with an ounce of 

cream and a teaspoonful of sugar. 
Six ounces of milk. 
Total about 250 calories. 



FEEDING DURING THE FOURTH HALF-YEAR 315 

1 1 a.m. or 12 m. Four ounces of thick vegetable or 
cereal soup. 

Two ounces of meat or fish. 

Two ounces of mashed potato or vegetable. 

One thick slice of bread with one teaspoonful 
of butter. 

Total about 300 calories. 
3 or 4 p.m. Two Graham or soda crackers. 

Six ounces of milk. 

Total about 200 calories. 
6 or 7 p.m. One egg or two ounces of custard. 

Slice of toast or a rusk. 

Six ounces of milk. 

Two ounces of cooked apples or prunes. 

Total about 250 calories. 

This gives a total food value for the day of about 
1000 calories, which is usually sufficient; the normal 
weight at this age being 11 to 12 kilograms (24 to 26 
pounds), we have an allowance of 80 to 90 calories 
per kilo, which should be ample. It must, however, 
be remembered that we cannot lay down any hard 
and fast rules on this subject; some children will 
get on well with 70 calories, whereas others require 
at least 100, and complain of hunger when kept on 
the above diet. 

Following C. H. Smith, I give the caloric values of 
various common articles of food, so that the reader 
mav make calculations for himself: 



316 THE FEEDING OF OLDER INFANTS 

Level tablespoon (approximately \ ounce) 

Cane-sugar 60 

Cream (10 per rent.) 50 

Butter 115 

Custard 20 

Fruit pulp 10 

Cereals 10 

Mashed vegetables 15 

Meat or fish 25 

Milk 10 

One cracker 30 

' thick slice of bread 75 

" egg 75 

These data are purposely given in round numbers, 
as any attempt at exactness is illusory; the above 
table will prove quite sufficient for all practical pur- 
poses. 

Not more than six ounces of water (one goblet) 
should be taken at meals when milk is omitted; 
excessive thirst, when not due to illness, is usually 
a sign that the food is too salty or sweet, and calls 
for a corresponding correction in this regard. 

Feeding Troubles. — During the second year, when 
the child begins to run about, great anxiety is often 
caused by a tendency of the weight to remain sta- 
tionary; the thick layer of subcutaneous fat, acquired 
during the latter half of the first year by normal babies, 
is gradually lost. This condition is physiological; 
we should not expect a total gain of more than six 
or seven pounds in the course of the second year; 
so long as the child's spirits, sleep, and digestion are 
manifestly good there is no occasion for worry. 

Real feeding difficulties are less common in the 
second year than in the first, but are by no means 
rare. A frequent occurrence is the persistent refusal 



FEEDING TROUBLES 317 

of common and wholesome foods, usually certain 
vegetables. For this there are two possible reasons: 
In the first place many young children have predomi- 
nantly carnivorous tastes; there is no great harm in 
an unusual craving for animal food, and, in the presence 
of this peculiarity, I do not hesitate to increase the 
ration of meat and eggs. Secondly, the insipid pre- 
paration of vegetables by the average American cook 
is largely responsible; the child simply has no relish 
for vegetables that taste like wet rags, and has trouble 
in overcoming this repugnance. In this event patience 
is necessary; we should see to tasty cooking of the 
vegetables, resorting to proper seasoning with salt, 
beef -juice, or meat-stock, and experiment with one 
variety at a time until the child learns to like it. We 
rarely have so much difficulty with other kinds of 
food; vegetables are evidently, to many children, an 
acquired taste. 

Occasionally a child will refuse to eat eggs; I have 
seen such cases in families where there was a history 
of egg-idiosyncrasy; in such an event it is probably 
wisest to give way to the infant's prejudices. 

Another common trouble is constipation, which 
sometimes is quite obstinate, especially in children 
who are suffering from rickets. It is desirable to cor- 
rect this through dietetic measures, if at all possible, 
for there are many grave objections to the routine 
use of laxatives. The following expedients are often 
effective: To begin with I usually give unstrained 
oatmeal a prominent place in the cereal part of the 
daily regimen, but in rare cases an idiosyncrasy to 



318 THE FEEDING OF OLDER INFANTS 

oats renders this method impracticable. Next, I 
order Graham crackers, which are keenly relished by 
most children, Graham bread, and the German rye- 
bread, all of which are more laxative than ordinary 
white bread or crackers. Thirdly, I give mashed 
stewed fruit daily, and have found prunes decidedly 
more laxative than apples or other fruits, and 
often my main reliance. It is only when dietetic 
measures fail that we should resort to enemas or 
suppositories. If rickets is at the bottom of the 
trouble we must give phosphorus in malt, which I 
prefer to cod-liver oil, as being more digestible and 
palatable. Laxatives should be a last resort, and 
then the best drug is cascara sagrada, in a dosage 
that must be adapted to the individual. Medication 
with magnesia, calomel, senna, and, worst of all, 
rhubarb, is in my opinion highly objectionable. 

In the fourth half-year it becomes necessary to 
give attention to the teeth, to proper habits of 
mastication, and the avoidance of bolting. Nervous 
children should be trained to attend strictly to busi- 
ness; the young gourmand who makes a rite of his 
meals is likely to do far better than the dreamer who 
allows his mind to wander from the food set before 
him. We must not forget that even at this early age 
the psychological study of the child becomes of great 
importance; some youngsters show signs of consider- 
able intelligence long before the age of two years, 
so that patience and tactfulness are no unimportant 
factors in inculcating proper habits of eating. The 
bolting of badly masticated food is a specially serious 



FEEDING TROUBLES 319 

fault; it may lead to severe attacks of indigestion, 
with violent symptoms, as undigested masses of food 
travel, almost unaltered, through the entire digestive 
tract. 

Some children give trouble as soon as attempts 
are made to vary their diet; these infants always 
present abnormalities in some other respects, with 
an almost invariable history of feeding difficulties 
during the first year. In these cases it often becomes 
necessary to return to formula-feeding for some weeks 
or months. I must, however, utter a word of caution 
against giving a low protein ration to these infants, 
as often advised; the trouble lies regularly with the 
cereal starches and never with the albuminous portion 
of the food. Carbohydrate overfeeding is indeed the 
usual error committed during the second year; many 
of these children get altogether too much cereal food, 
including bread and crackers, and if thereto is added 
an excess of potatoes or cane-sugar it is no wonder 
if we occasionally witness digestive upsets, often with 
fever, such as have already been described in carbo- 
hydrate and acid intoxications in younger infants. 
In fact the third half-year is by no means immune 
to the dangerous digestive disturbances of early 
infancy, and the mortality at this age in the summer 
months is not at all insignificant. This accounts for 
the popular impression as to the dangers of the 
second summer, which is well founded as regards 
such infants as have been fed at the breast during 
their first year. 

This type of infant is best handled by imagining 



320 THE FEEDING OF OLDER INFANTS 

it to be three or six months younger than its actual 
age, and feeding accordingly. It is safer to overlook 
a slight retardation of growth than to try to force 
the infant up to a regimen, of which the effective 
disposal is far beyond its feeble digestive powers. 



BIBLIOGRAPHY. 



Abt. — Arch, of Pediat., November, 1909. 
Ackermann. — Inauguraldiss., Munchen, 1908. 
Adami. — British Med. Jour., January 24, 1914. 
Alexander and Bullowa. — Arch, of Pediat., January, 1910. 
Allaria. — 1. Rivista di clin. pediat., June, 1912. 

2. Ibid., July, 1912. 
Aron.— Biochem. Zeits., 1908, v. 12. 
Aronstamm. — Arch. f. Kinderh., 1903, v. 37. 
Aschenheim. — Monatss. f. Kinderh., 1913. v. 12. 
Auche et Campana. — Revue mens, des malad. des enf., 1906, v. 24. 
Avignaret et al. — Arch, de med. des enfants, 1912. 

Baginsky. — 1. Lehrbuch der Kinderkrankh., 1905. 

2. Arch. f. Kinderh., 1888, v. 9. 

3. Berliner klin. Woch., 1894, No. 43. 
Bahrdt.— Jahrb. f. Kinderh., 1910, v. 71. 

Bahrdt u. Bamberg. — Zeits. f. Kinderh., 1911, v. 3. 
Bahrdt u. Edelstein — Zeits. f. Kinderh., 1911, v. 1. 
Baker.— Arch, of Pediat., March, 1914. 
Bamberg.— Zeits. f. Kinderh., 1913, v. 6. 
Bauer.— New York Med. Jour., March 12, 1898. 
Barlow.— Trans. Royal Med. and Chir. Soc, 1883. 
Basch. — Miinchener med. Woch., October 24, 1911. 
Bauer.— 1. Deutsche med. Woch., 1909, No. 38. 

2. Monatss. f. Kinderh., 1911, v. 10. 
Beardsley. — Reprinted in Arch, of Pediat., May, 1903. 
Beattie and Lewis. — Jour, of Patholog. and Bacteriol., 1913, v. 18. 
Beck.— 1. Monatss. f. Kinderh., 1904, No. 5. 

2. Ibid., 1912, v. 11. 
Behring.— Deutsche med. Woch., 1903, No. 39. 
Bendix.— 1. Zeits. f. Kinderh., 1913, v. 6. 

2. Deutsche Aerztezeitung, 1904. 
Bendix u. Bergmann. — Monatss. f. Kinderh., 1912, v. 11. 
Benfey.— Jahrb. f. Kinderh., 1912, v. 75. 
Berend.— Monatss. f. Kinderh., 1913, v. 12. 
Berg.— Biochem. Zeits., 1910, v. 30. 

Bernheim-Karrer. — Correspond, f. schweizer Aerzte, 1907, No. 19. 
Bickel u. Roeder. — Berliner klin. Woch., Januarv 3, 1910. 
' 21 



322 BIBLIOGRAPHY 



Biedert. — Virchow's Archiv., 1874, v. 60. 
Birk.— 1. Monatss. f. Kinderh., 1911, v. 10. 

2. Ibid., 1910, v. 9, p. 595. 

3. Ibid., June, 1908. 

4. Berliner klin. Woch., July 3, 1911. 

5. Monatss. f. Kinderh., 1910, v. 9, p. 279. 

6. Ibid., 1910, v. 9, p. 140. 
Bischoff.— Arch. f. Hygiene, 1903, v. 47. 
Bluhdorn.— Monatss. f. Kinderh., 1913, v. 12. 
Boissonas. — Arch, de med. des enf., 1908, v. 11. 
Bordet.— Ann. de l'Inst. Pasteur, 1899, v. 13. 
Bourdillon. — Rev. med. de la Suisse romande, 1907, No. 20. 
Bovaird. — Arch, of Pediat., June, 1909. 

Bowditch and Bosworth. — American Jour. Dis. Child., -March, 1914. 
Brady.— 1. Arch, of Pediat., June, 1910. 

2. American Jour. Dis. Child., August, 1912. 
Brennemann. — 1. American Jour. Dis. Child., May, 1911. 

2. Jour. Amer. Med. Assoc, February 22, 1913. 
Bruck.— Monatss. f. Kinderh., 1909, No. 8. 
Briining.— Arch. f. Kinderh., 1913, v. 60 and 61. 
Brush. — Jour. Amer. Med. Assoc, June 20, 1903. 
Budde. — Milk and its Treatment, 1896. 
Budin et Planchon. — Rev. d'hyg. et med. infant., 1904, v.. 3. 

Calvary.— 1. Ergeb. d. inn. Med. u. Kinderh., 1913, v. 10. 

2. Zeits. f. Kinderh., 1911, v. 1. 
Camerer u. Soldner.— Zeits. f. Biologie, 1898, v. 36. 
Cardamatis. — Arch, de med. des enf., 1904, No. 2. 
Cassel.— Arch. f. Kinderh., 1912, v. 58. 
Chapin.— 1. New York Med. Jour., February 23, 1901. 

2. Ibid., April 23, 1904. 

3. Med. Record, February 18, 1905. 

4. Ibid., May 28, 1910. 

5. American Med., March 4, 1905. 
Chevalier. — La clinique infant., 1907, No. 20. 

Chittenden and Griswold. — American Chem. Jour., 1882, v. 3. 
Chittenden and Mendel. — Osier's Mod. Med., v. 1. 
Clarke. — Amer. Jour. Med. Sci., May and June, 1909. 
Clock. — Jour. Amer. Med. Assoc, July 19, 1913. 
Comby. — Archiv de med. des enf., 1906, v. 10. 
Concetti. — 1. Rivista di clin. pediat., January, 1905. 

2. Arch. f. Kinderh., 1909. v. 50. 
Connstein. — Arch. f. Anat. u. Physiol., 1899. 
Coolidge. — Arch, of Pediat., October, 1905. 
Coplans. — Lancet, October 19, 1907. 
Cornet. — Nothnagel, spec. Pathol, u. Therap., v. 14. 
Cowie and Hubbard. — Amer. Jour. Dis. Child., September, 1913. 
Cramer. — 1. Munch, med. Woch., November 13, 1900. 

2. Monatss. f. Kinderh., January, 1908. 

3. Arch. f. Kinderh.. 1900, v. 32. 



BIBLIOGRAPHY 323 

Cronheim, J. u. W. — Zeits. f. phys. u. cliiit. Therap., 1910, v. 14. 
Oronheim u. Midler. — Jahrb. f. Kinderh., 1903, v. 57. 
Curschmann. — Deutsche Zeits. f. Nervenh., 1910, v. 39. 
Cybulski. — Monatss. f. Kindcrh., November, 1906. 
Czerny. — 1. Prager med. Woch., 1893, Nos. 41 and 42. 

2. Monatss. f. Kinderh., 1905, No. 1. 

3. Ibid., 190G, No. 11. 

4. Ibid., 1907, No. 1. 

Czerny u. Keller. — Des Kindes Ernahrung. 

Davidsohn.— Zeits. f. Kinderh., 1911, v. 2. 

Davis. — Boston Med. and Surg. Jour.. February 15, 1918. 

Decherf. — Archiv. de med. des enf., January, 1905. 

de Jager. — Nederl. Tijds. v. Geneesk., 1895. 

de Jong.— Nederl. Tijds. v. Geneesk., 1909, v. 1. 

Deutsch.— Monatss. f. Kindcrh., 1906, No. 7. 

Dibbelt.— Beitr. z. path. Anat. u. allg. Pathol., 1910, v. 48. 

Dombrowsky. — Arch. f. Hygiene, v. 50. 

Donath.— Wiener med. Woch., 1910, No. 48. 

Dubois u. Stolte.— Jahrb. f. Kinderh., 1913, v. 77. 

Dunn.— 1. Arch, of Pediat., April, 1907. 

2. Ibid., June, 1905. 

3. Boston Med. and Surg. Jour., November 18, 1909. 

4. Jour. Amer. Med. Assoc, August 21, 1909. 
Duval and Bassett. — Amer. Med., September 13, 1902. 

Edsall.— Amer. Jour. Med. Sci., April, 1903. 
Edsall and Fife. — New York Med. Jour., January 9, 1904. 
Edsall and Miller. — Amer. Jour. Med. Sci., April, 1905. 
Engel.— 1. Arch. f. Kinderh., 1906, v. 43. 

2. Deutsche med. Woch., June 26, 1913. 
Engel u. Bode. — Zeits. f. physiol. Chemie, 1911, v. 74. 
Epstein.— Prager med. Woch., 1896, No. 43. 
Erving. — Arch, of Intern. Med., December, 1908. 
Escherich. — 1. Die Darmbakterien im Sauglingsalter, 1886. 

2. Verh. d. Gesells. f. Kinderh., 1894. 

3. Wiener klin. Woch., 1890, No. 40. 

4. Munch, med. Woch., 1889, No. 13. 
Esser.— Munch, med. Woch., 1908, No. 17. 
Eustache. — Ann. de med. et chirurg. inf., 1904, No. 5. 

Feer.— 1. Jahrb. f. Kinderh., 1902, v. 56. 

2. Korrespond. f. Schweizer Aerzte., 1904, No. 1. 

3. Jahrb. f. Kinderh., 1913, v. 78. 

Fife and Veeder. — Amer. Jour. Dis. Child., July, 1911. 
Finkelstein. — 1. Lehrbuch d. Sauglingskrankheiten. 

2. Therap. Monatsch., October, 1907. 

3. Monatss. f. Kinderh., 1905, No. 5. 

4. Jahrb. f. Kinderh., 1908, v. 68. 

5. Deutsch. med. Woch.. 1909, No. 5. 



324 BIBLIOGRAPHY 



Finkelstein.— G. Jahrb. f. Kinderh., 1907, v. 65 and G6. 

7. Amer. Jour. Dis. Child., May, 1912. 

8. Berliner klin. Woch., October 9, 1911. 

9. Mediz. Klinik, 1907. 

10. Zeits. f. Kinderh., 1914, v. 8. 
Finkelstein u. Meyer.— 1. Barliner klin. Woch., June 20. 19 f() 

2. Munch, med. Woch., February 14, 1911. 
Flexner. — Johns Hopkins Hosp. Bull., 1900, v. 11. 
Flexner and Holt. — -Studies from the Rockefeller Inst., 1904. 
Folin. — Jour. Amer. Med. Assoc, September 5, 1914. 
Forest.— Arch. f. Kinderh., 1905, v. 42. 
Francioni. — Rivista di clin. pediat., July, 1911. 
Frank.— Monatss. f. Kinder., 1913, v. 12. 

Frank u. Schittenhelm. — Zeits. f. physiol. Chem., 1911, v. 73. 
Freudenberg u. Klocmann. — -Jahrb. f. Kinderh., 1913. v. 78. 
Freund.— 1. Biochem. Zeits., 1909, v. 16. 

2. Jahrb. f. Kinderh., 1904, v. 59. 

3. Zeits. f. physiol. Chemie, 1900, v. 29. 

4. Monatss. f. Kinderh., 1908, No. 10. 
Frew. — Lancet, November 4, 1911. 

Friberger. — Miinchener med. Woch., 1909, No. 38. 
Friedjung u. Hecht.— Arch. f. Kinderh., 1903, v. 37. 
Friedlander. — Jour. Amer. Med. Assoc, December 19, 1908. 
Friedlander and Greenbaum. — Arch, of Pediat., September, 1912 
Frost. — Arch, of Pediat., January, 1912. 

Garrod. — Edinburgh Month. Jour, of Med., 1848. 
Gartner.— Verh. d. Ges. f. Kinderh., 1894. 
Genersich. — Budapesti Orvosi Ujsag, 1910. 
Gewin— Nederl. Tijds. v. Geneesk., 1912, v. 48. 
Glaessner. — Wiener med. Woch., 1906, No. 40. 
Glisson. — -English Trans., 1651. 
Goodall. — Arch, of Pediat., January, 1911. 
Griffith.— New York Med. Jour., February 23, 1901. 
Grosz. — Arch. f. Kinderh., 1905, v. 41. 
Grulee. — 1. Arch, of Pediat., June, 1904. 

2. Amer. Jour. Dis. Child., September, 1911. 
Grulee and Buhlig. — Arch, of Pediat., October, 1911. 

Haas. — Arch, of Pediat., March, 1914. 

Hammer.— Bull. Iowa Agric Exper. Sta., 1914, No. 15. 

Hansemann. — 1. Berliner klin. Woch., February 26, 1906. 

2. Ibid., 1899, No. 11. 
Hart.— Jahrb. f. Kinderh., 1912, v. 76. 
Hartjc— Jahrb. f. Kinderh., 1911, v. 73. 
Hastings. — Jour. Amer. Med. Assoc, April 30, 1904. 
Hecht.— Munch, med. Woch., 1908, No. 19. 
Heim u. John. — Monatss. f. Kinderh., 1912, v. 11. 

2. Zeits. f. Kinderh., 1911, v. 3. 
Heiman.— 1. Arch, of Pediat., August, 1910. 



BIBLIOGRAPHY 325 



Heiman. — 2. Ibid., December, 1911. 

Hclbich.— Monatss. f. Kinderh., 1911, v. 10. 

Hemenway. — Jour. Amer. Med. Assoc., April 4, 190S. 

Henoch.— Berliner klin. Woch., 1876, No. 18. 

Herrman. — Arch, of Pediat., July, 1911. 

Hess, A. P.— 1. Amer. Jour. Dis. Child., March, 1913. 

2. Ibid., May, 1912. 

3. Ibid., October, 1912. 

4. Deutsche med. Woch., 1912, No. 9. 

5. Amer. Jour. Dis. Child., March, 1914. 

Hess, J. H. — Amer. Jour. Dis. Child., November, 1911. 
Heubner.— Jahrb. f. Kinderh., 1890, v. 32. 

2. Therap. d. Gegenwart, 1906, No. 10. 
Heubner, O. and W.— Jahrb. f. Kinderh., 1910, v. 72. 
Hichens. — British Jour. Child. Dis., September, 1913. 
Hirschsprung.— 1. Jahrb. f. Kinderh., 1888, v. 28. 

2. Henoch's Festschrift, 1890. 
Hochsinger. — Deutsche Klinik, v. 7. 
Hoffmann. — Ziegler's Beitrage, 1905. 
Hoist and Frolich. — Jour, of Hygiene, October, 1907. 
Holt. — 1. Diseases of Infancy and Childhood. 

2. Arch, of Pediat., November, 1906. v 

3. Ibid., January, 1905. 

4. Med. News, July, 1905. 

5. Jour. Amer. Med. Assoc, June 27, 1914. 

Holt and Levene. — Amer. Jour. Dis. Child., November, 1912. 
Hoobler. — 1. Arch, of Pediat., November, 1910. 

2. Amer. Jour. Dis. Child., August, 1911. 

3. Arch, of Pediat., March, 1914. 

Howland and Dana. — Amer. Jour. Dis. Child., July, 1913. 
Hunaeus. — Biochem. Zeits., 1909, v. 22. 

Hunziker. — New York Agric. Exper. Sta. Bull., No. 197, p. 61. 
Hutchison. — Osier's Mod. Med., v. 1. 

Ibrahim.— 1. Zeits. f. physiol. Chem., 1910, v. 64. 

2. Monatss. f. Kinderh., 1911, v. 10. 

3. Die angeborene Pylorusstenose im Sauglingsalter, 1905. 

4. Therap. Monatsch., 1908, p. 560. 

5. Deutsche med. Woch., 1905, No. 23. 

Jacobi. — 1. New York State Jour, of Med., July, 1906. 

2. Gerhardt's Handbuch d. Kinderh., 1876. 
Jacobson. — Arch, de med. des enf., 1909. 
Jalland. — Med. Times and Gaz., 1873. 
v. Jaksch.— Wiener klin. Woch., 1889, No. 22. 
Jaschke.— 1. Med. Klinik, August, 1908. 

2. Monatss. f. Geburtsh. u. Gynakol., 1909, v. 29. 
Jehle u. Pincherle. — Wiener klin. Woch., 1910, No. 3. 
Jordan and Mott. — Amer. Jour. Public Hygiene, 1910. 



320 BIBLIOGRAPHY 

Kassowitz. — 1. Zeits. f. klin. Med., 1883, v. 7. 

2. Beitrage z. Kinderh., 1893. 

3. Jahrb. f. Kinderh., 1884, v. 19. 
Katzenellenbogen. — Monatss. f. Kinderh., 1911, v. 10. 
Keller.— 1. Arch. f. Kinderh., 1900, v. 29. 

2. Monatss. f. Kinderh., 1910, v. 9. 

3. Die Malzsuppe, 1904. 

4. Berliner klin. Woch., September 3, 1906. 
Kendall. — Boston Med. and Surg. Jour., November 20, 1913. 
Kendall and Smith.— Boston Med. and Surg. Jour., March 2, 1911. 
Kerley and Campbell. — New York Med. Jour., January 27, 1906. 
Kleinschmidt.— Monatss. f. Kinderh., 1912, v. 11. 

Klotz.— 1. Monatss. f. Kinderh., 1911, v. 10. 

2. Ibid., 1909, No. 8. 

3. Ibid.. 1907, No. 5. 

Knopf elmacher.— Med. Klinik, 1908, No. 34. 
Knox. — Jour. Amer. Med. Assoc, December 17, 1904. 
Knox and Schorer. — Johns Hopkins Hosp. Rep., 1910, v. 15. 
Knox and Tracy. — Amer. Jour. Dis. Child., June, 1914. 
Kober.— Amer. Jour. Med. Sci., October, 1903. 
Koeppe.— 1. Monatss. f. Kinderh., 1908, No. 6. 
2. Deutsche med. Woch., June 17, 1909. 
Kolff u. Noeggerath.— Jahrb. f. Kinderh., 1909, v. 70. 
Koplik. — 1. Diseases of Infancy and Childhood, 1906. 

2. New York Med. Jour., November 27, 1909. 

3. Amer. Jour. Med. Sci., July, 1908. 

4. Arch, of Pediat., March, 1907. 

5. New York Med. Jour., January 31, 1891. 
Krasnogorski. — Jahrb. f. Kinderh., 1910, v. 72. 

Ladd.— 1. Arch, of Pediat., October, 1904. 

2. Ibid., March, 1908. 

3. Ibid., May, 1912. 

4. Boston Med. and Surg. Jour., January 1, 1903. 

5. Arch, of Pediat., June, 1910. 

La Fetra and Howland. — Arch, of Pediat., March, 1904. 
Laisney.— Th&se de Paris, 1903. 
Lamb.— Arch, of Pediat., June, 1908. 
Langstein.— 1. Jahrb. f. Kinderh., 1911, v. 74. 

2. Ibid., 1906, v. 64. 

3. Zeits. f. Kinderh., 1912, v. 5. 

Langstein u. Meyer. — Jahrb. f. Kinderh., 1905, v. 61. 
Langstein, Rott u. Edelstein.— Zeits. f. Kinderh., 1914, v. 8. 
Laurentius. — -Arch. f. Kinderh., 1911, v. 56. 
Leiner. — Wiener klin. Woch., 1904, No. 25. 
Leo.— Berliner klin. Woch., 1888, No. 49. 
Leopold.— 1. Zeits. f. Kinderh., 1911, v. 1. 

2. Arch, of Pediat., January, 1914. 

3. Amer. Jour. Dis. Child., August, 1914. 
Lewi.— See Holt. 1. 



BIBLIOGRAPHY 327 



v. Liebig. — Suppe fur Sauglinge, 1865. 
Liepmann. — Berliner klin. Woch., 1912, No. 30. 
Lissauer. — Jahrb. f. Kinder]]., 1903, v. 58. 
Litzenberg. — Amer. Jour. Dis. Child., December, 1912. 
Lucas. — 1. Arch, of Pediat., October, 1913. 

2. Boston Med. and Surg. Jour., September 3, 1908. 
Lust.— 1. Monutss. f. Kinderh., 1912, v. 11. 

2. Med. Klinik, 1912, No. 43. 

3. Monatss. f. Kinderh., 1911, v. 10, p. 316. 

4. Jahrb. f. Kinderh., 1913, v. 77. 

5. Monatss. f. Kinderh., 1911, v. 10, p. 420. 

6. Munch, med. Woch., 1913, No. 37. 

McClure. — Amer. Jour. Dis. Child., January, 1914. 
McCollum and Davis. — Jour. Biol. Chem., 1913, v. 15. 
McLean.— Zeits. f. Kinderh., 1912, v. 4. 
Malagodi.— Rivista clin. pediat., October, 1909. 
Marfan. — 1. Rev. des maladies de l'enf., 1895. 

2. Arch, de med. des enf., November, 1901. 
Mayerhofer u. Pribram. — Monatss. f. Kinderh., 1910, v. 9. 
Mazzeo. — La pediatria, 1905, No. 2. 
Meeh.— Zeits. f. Biologic, 1879, v. 15. 
Meigs.— Milk Analysis and Infant-feeding, 1885. 
Meltzer and Auer. — Jour. Exp. Med., 1906. 
Mendel. — 1. Jour. Amer. Med. Assoc, September 5, 1914. 

2. Amer. Journ. of Physiol., 1909, v. 24. 
Menschikoff. — Monatss. f. Kinderh., 1910, v. 9. 
Metchnikoff.— The Prolongation of Life, 1907. 
Meyer, K.— Jahrb. f. Kinderh., 1913, v. 77. 
Meyer, L. P.— 1. Zeits. f. Kinderh., 1912, v. 5. 

2. Monatss. f. Kinderh., 1906, No. 7. 

3. Berliner klin. Woch., 1907, No. 46. 

4. Jahrb. f. Kinderh., 1910, v. 71. 

Meyer and Leopold. — Arch, of Pediat., October, 1909. 

Meyer u. Rietschel. — Berliner klin. Woch., December 14, 1908. 

Michael. — Jour. Infect. Dis., January, 1905. 

Michel.— L'obstetrique, 1896, p. 140. 

Miller and Wilcox.— Lancet, 1907, No. 23. 

Millon. — La pathologie infant., November 15, 1908. 

Milner and Atwater. — Dietetics, Encycl. Brit., 11th ed. 

Moller. — Medic. Jahrbucher, 1859. 

Mori. — Monatss. f. Kinderh., May, 1905. 

Moro.— 1. Arch. f. Kinderh., 1906, v. 43. 

2. Jahrb. f. Kinderh., 1902, v. 56. 

3. Arch. f. Kinderh., 1904, v. 40. 

4. Miinchener med. Woch., 1908, No. 31. 
Moro u. Kolb. — Monatss. f. Kinderh., 1910, v. 9. 

Morse. — 1. New Orleans Med. and Surg. Jour., August, 1910. 

2. Amer. Jour. Med. Sci., March, 1904. 

3. Amer. Jour. Obstet., May, 1910. 



328 BIBLIOGRAPHY 

Morse — 4. Amer. Jour. Dis. Child., November, 1911. 

5. Boston Med. and Surg. Jour., May 28, 1903. 

6. Arch, of Pediat,, August, 1905. 

7. Jour. Amer. Med. Assoc., April 14, 1906. 

8. Amer. Jour. Dis. Child., May, 1911. 

9. Amer. Jour. Med. Sci., November, 1912. 
10. New York Med. Jour., March 8, 1913. 

Morse and Bowditch. — Arch, of Pediat., December, 1906. 
Muller.— 1. Jahrb. f. Kinderh., 1911, v. 73. 
2. Therap. Monatsh., July, 1903. 

Naunyn. — Nothnagel's spec. Pathol, u. Therap., v. 7, pt. 1 
Neumann. — Berliner klin. Woch., 1905, No. 1. 
Niemann. — 1. Jahrb. f. Kinderh., 1911, v. 74. 

2. Jahrb. f. Kinderh., 1914, v. 79. 
Nolf.— Le scalpel, 1910, No. 52. 
Northrup. — Arch, of Pediat., January, 1905. 
Nothmann.— 1. Arch. f. Kinderh., 1909, v. 51. 

2. Monatss. f. Kinderh., 1909, No. 7. 

3. Zeits. f. Kinderh., 1911, v. 1. 

Ohno.— Philippine Jour, of Sci., 1906, v. 1. 
Oppenheimer. — Monatss. f. Kinderh., May, 1907. 
Oppler.— Monatss. f. Kinderh., 1903, No. 10. 
Orchard.— Arch, of Pediat,, May, 1914. 
Orgler. — Zeits. f. experim. Pathol, u. Therap., 1908, v. 5 

2. Ergeb. d. inn. Med. u. Kinderh., 1908, v. 2. 
Osborne and Mendel. — Jour. Biol. Chcm., 1913, v. 16. 
Ott and Scott.— Therap. Gazette, October 15, 1911. 

Park.— 1. Jour. Med. Research, 1904, v. 11. 

2. Arch, of Pediat., June, 1910. 
Park and Holt. — Arch, of Pediat., December, 1903. 
Pedley.— British Med. Jour., October 20, 1906. 
Peiser. — Deutsche med. Woch., September 12, 1912. 

2. Monatss. f. Kinderh., 1912, v. 11. 
Pelka.— Zeits. f. Kinderh., 1911, v. 2. 

Perier. — Ann. de med. et chirurg. inf., 1903, Nos. 5 and 20. 
Pfaundler. — 1. Therap. der Gegenw., January, 1911. 

2. Wiener klin. Woch., 1898, No. 45. 

3. Munch, med. Woch., September 15, 1903. 
Pfeisdorf u. Stolte.— Monatss. f. Kinderh., 1912, v. 11. 
Philips. — 1. "Monatss. f. Kinder., April, 1907. 

2. Ibid., November, 1906. 
Pisek.— Arch, of Pediat., October, 1904. 
Plantenga.— Arch. f. Kinderh., 1912, v. 58. 
Porter. — Amer. Jour. Dis. Child., August, 1913. 
Potter. — Med. News, January 9, 1904. 
Poynton. — Lancet, August 13, 1904. 



BIBLIOGRAPHY 329 

Quincke. — Arch. f. expcr. Pathol, u. Pharmakol., 1885, v. 19. 

Raw.— British Med. Jour., August 18, 1906. 
Reed and Ward. — Amer. Med., February 14, 1903. 
Rehn.— Med. Klinik, 1907, No. 20. 
Reinach.— Jahrb. f. Kinderh., 1904, v. 59. 
Reuben. — Arch, of Pediat., March, 1914. 
v. Reuss.— Zeits. f. Kinderh., 1912, v. 4. 
Rietschel — Monatss. f. Kinderh., 1910, v. 9. 
Rivas. — Pediatrics, August, 1904. 
Rommel.— Arch. f. Kinderh., 1903, v. 57. 
Rosenow. — Jour. Infect. Dis., November, 1912. 
Rosenstern. — 1. Deutsche med. Woch., 1912, No. 39. 
2. Ergeb. d. inn. Med. u. Kinderh, 1911, v. 7. 
Rosenthal.— Nord. Tidskr. f. Terapi, 1906. 
Rotch. — 1. Arch, of Pediat., August, 1904. 

2. Jour. Amer. Med. Assoc, August 8, 1903. 

3. Amer. Med., May 7, 1904. 

4. Arch, of Pediat., February, 1893. 

5. Text-book on Pediatrics, 1901. 

Rotch and Kendall. — Amer. Jour. Dis. Child., July, 1911. 
Rott.— Zeits. f. Kinderh., 1912, v. 5. 
Rubner u. Heubner.— Zeits. f. Biologie, 1899, v. 38. 
Rudnik.— Wiener klin. Woch., 1906, No. 51. 
Ruhrah.— 1. Arch, of Pediat., July, 1909. 

2. Amer. Jour. Med. Sci., April, 1914. 

Salge.— 1. Jahrb. f. Kinderh., 1912, v. 76. 

2. Zeits. f. Kinderh., 1911, v. 2. 
Samelson — 1. Zeits. f. Kinderh., 1911, v. 2. 

2. Monatss. f. Kinderh., 1912, v. 11. 
Schabad.— Zeits. f. klin. Med., 1910, v. 69. 

2. Jahrb. f. Kinderh., 1911, v. 74. 

3. Monatss. f. Kinderh., 1910, v. 9. 
Schaps.— Berliner klin. Woch., May 13, 1907. 
Schereschewsky. — Arch, of Pediat., December, 1913. 
Schkarin — Monatss. f. Kinderh., 1910, v. 9. 
Schloss, E — 1. Jahrb. f. Kinderh., 1910, v. 71. 

2. Ueber Sauglingsernahrung, 1912. 
Schloss, O. M.— Amer. Jour. Dis. Child., June, 1912. 
Schloss and Crawford. — Amer. Jour. Dis. Child., March,' 1911. 
Schloss u. Frank.— Bioch. Zeits., 1914, v. 60. 
Schlossmann. — 1. Monatss. f. Kinderh., 1905, v. 4. 

2. Arch. f. Kinderh., 1900, v. 30. 
Schlossmann u. Murschhauser. — Biochem. Zeits., 1910, v. 26. 
Schlutz. — Amer. Jour. Dis. Child., February, 1912. 
Schorer. — Amer. Jour. Dis. Child., April, 1912. 
Schrack— Jahrb. f. Kinderh., 1889, v. 29. 
Schulz. — Munchener med. Woch., February 13, 1912. 



330 BIBLIOGRAPHY 



Schwarz. — 1. Amer. Jour. Dis. Child., September, 1911. 

2. Arch, of Pediat., September, 1911. 
Schwyzer.— Bioch. Zeits., 1914, v. 60. 
Sedgwick.— 1. Jahrb. f. Kinderh., 1906, v. 04. 

2. Jour. Amer. Med. Assoc, October 1, 1910. 
Sedgwick and Schlutz. — Amer. Jour. Dis. Child., October, 1911. 
Seibert.— Med. Record, March, 1888. 

Sharpies and Darling. — Boston Med. and Surg. Jour., April 16, 1905. 
Shelmerdine. — New York Med. Jour., March 14, 1908. 
Shiga.— Centralbl. f. Bacterid., 1898, v. 23. 
Siegert,— 1. Verh. d. Gesells. f. Kinderh., 1903. 

2. Monatss. f. Kinderh., January, 1907, v. 5. 
Siegfried. — Zeits. f. physiol. Chem., 1896, v. 21 and 22. 
Smith, C. H.— Arch, of Pediat., November, 1912. 
Smith, R. M. — Boston Med. and Surg. Jour., November 20, 1913. 
Smith, Theobald. — Boston Med. and Surg. Jour., September 26, 
1907. 

Snow. — Arch, of Pediat., August, 1905. 

South worth.— 1. Arch, of Pediat., March, 1910. 

2. Ibid., February, 1907. 

3. Ibid., September, 1912. 

4. Ibid., February, 1905. 

Southworth and Schloss. — Arch, of Pediat., April, 1909. 
Spolverini. — 1. Riv. di clin. pediat., 1904, No. 2. 

2. Arch, de med. des enfants, March, 1904. 

3. Revue d'hyg. et de med. infant., 1908, No. 2. 
Steele. — Arch, of Pediat., January, 1910. 
Steinitz.— Monatss. f. Kinderh., 1902, No. 4. 

Stern. — Arch, of Pediat., June, 1905. 
Still.— British Med. Jour., July 28, 1906. 
Stolte.— 1. Jahrb. f. Kinderh., 1911, v. 74. 

2. Munch, med. Woch., December 17, 1912. 
Stoltzner.— Jahrb. f. Kinderh., 1906, v. 63. 
Stuhl.— Deutsche med. Woch., June 17, 1909. 
Szekely. — Orvosi Hetilap., June 4, 1903. 

Talbot.— 1. Amer. Jour. Dis. Child., March, 1911. 

2. Boston Med. and Surg. Jour., June 11, 1908. 

3. Arch, of Pediat., December, 1909. 

4. Amer. Jour. Dis. Chil., June, 1914. 

Talbot and Hill.— Amer. Jour. Dis. Child., August, 1914. 
Teixeira de Mattos— Jahrb. f. Kinderh., 1902, v. 55. 
Thiemich.— 1. Munch, med. Woch., 1910, No. 26. 

2. Jahrb. f. Kinderh., 1896, v. 44. 
Tobler u. Bogen. — Monatss. f. Kinderh., 1908, No. 1. 
Tonney and Pillinger. — Jour. Amer. Med. Assoc, May 18, 1912. 
Torrey and Rahe. — Jour, of Infect. Dis., v. 1. 
Townsend. — Boston Med. and Surg. Jour., February 17, 1887. 
Triboulet— Bull, de la soc pediat. de Paris, 1909, p. 512. 
Tugendreich.— Arch. f. Kinderh., 1900, v. 44. 



BIBLIOGRAPHY 331 



Uffenheimer. — Ergeb. d. inn. Med. u. Kinderh., 1908, v. 2. 
Usuki.— Jahrb. f. Kinderh., 1910, v. 72. 

Van Slyke.— Arch, of Pediat., July, 1905. 

Variot.— 1. Bull, de la Soc. pediat. de Paris, 1913, p. 43. 

2. British Med. Jour., May 14, 1904. 
Vincent. — Amor. Jour. Dis. Child., February, 1914. 
Vipond. — Montreal Med. Jour., April, 1910. 
Vogt. — Monatss. f. Kinderh., January, 1910, v. 8. 
Voix — These de Paris, 1903. 

Volhard. — Munch, med. Woch., 1900, Nos. 5 and 6. 
Voltz— Biochem. Zeits., 1913, v. 52. 

Wachenheim. — 1. New York Med. Jour., September 9, 1905. 

2. Amer. Jour. Med. Sci., April, 1905. 

3. The Climatic Treatment of Children, 1907. 

4. Med. News, January 16, 1904. 
Wassermann. — Verh. d. 18. Kongr. f. inn. Med., 1900. 
Weaver and Tunnicliff. — Jour, of Inf. Dis., January, 1905. 
Weiland.— Berliner klin. Woch., July 13, 1908. 

Weill et Mouriquond. — Jour, de med. de Paris, June, 1912. 
Weiss. — Volkmann's klin. Vortrage, 1880. 
Wernstedt. — Monatss. f. Kinderh., August, 1905. 
Westcott— Arch, of Pediat., March, 1907. 
Whitehead. — Amer. Jour, of Physiol., 1909, v. 24. 
Wilcox and Hill. — Amer. Jour. Dis. Child., April, 1913. 
Wile. — Jour. Amer. Med. Assoc, March 16, 1912. 
Williamson. — London and Edinburgh Month. Jour., 1841. 
Winslow. — Boston Med. and Surg. Jour., December 14, 1911. 
Wollstein. — Jour. Med. Research, August, 1903. 
Wright.— Lancet, July 22, 1893. 

Zahorsky. — Amer. Jour. Dis. Child., November, 1913. 
Zaitschek. — Arch. f. d. ges. Physiologie, 1904, v. 54. 
Zappert u. Jolles. — Berliner klin. Woch., 1903, No. 41. 
Zlocisti. — Berliner klin. Woch., February 1, 1904. 
Zuckerkandl.— Wiener klin. Woch., 1905, No. 33. 



INDEX. 



Acetone, 82, 224-5, 274 
Acetonemia and Acetonuria, 

223, 276 
Achondroplasia, 290 
Acid, boric, 103 

hydrochloric, 17, 20-1 
Acidosis, 156, 224, 174-8, 287, 

298 
Acids, fatty, 18, 22, 28, 33-4, 
51, 82, 116, 166-70 
in cow's milk, 82, 115-6, 

166-70 
in human milk, 51 
Adenoids, 270 
Albumen-water, 177, 261 
Albumin-cream-milk, 122-3 

-milk, 118-22, 263-6 
Albuminuria and nursing, 59-60 
Albumose, 164 
Alcohol, 54, 64, 164-5, 169-70, 

260, 314 
Alkalies (see also Potassium, 
Sodium). 

in acidosis, 282-3 

addition to milk, 160-2 

gastric secretion and, 18 
Amino-acids, 21, 23 
Ammonia, 23, 25, 37, 275 
Amylase (see Diastase). 
Anaphylaxis, 281-2 

to cow's milk, 108-9 

to eggs, 177, 281 
Anasarca (see Edema). 
Anemia in infants, 86, 272-4 

nursing and, 60 
Anorexia, 219 



Antisepsis, internal, 21 
Aphtha?, Bednar's, 67 
Apples, 181, 314, 318 
Aromatics as galactagogues, 54 
Asparagus, 314 
Asthma dyspepticum, 238 
Atrophy from milk, 195, 213-41, 
244, 263 

from salts, 230 

from starch, 147, 172, 223-5, 
229, 276-7, 298, 310 
Auto-intoxication, 240 



B 



Baby foods, 171-3 
Bacillus cyanogenes, 76 

dysentery, 249-50 

gas-forming, 251 

lactic acid, 32, 115, 166-9, 
240 

tuberculosis, 89, 267-8 
Bacteria, diarrhea and, 22, 234, 
240, 248-51 

in milk, 87-93, 97 

in top-milk, 125 

relation to carbohydrates, 32, 
263 
Bacterium coli, 251 
Banana meal, 180 
Barley, 34, 79, 148, 185, 190 
Beans, 178 

soy, 179 

string, 314 
Beef -extract, 176 

juice, 174-5 
Beer as galactagogue, 54, 64 



334 



INDEX 



Bile, 20 

Bismuth, 260 

Blood (see Anemia, Hemo- 
globin, Leukocytosis). 

Bones, 39 (see also Rickets). 

Bottle-feeding (see Feeding, 
artificial). 

Bottles (see Modification, 
home). 

Bread, 313-4, 316, 318-9 

Breast, 53-7, 62, 66 
of newborn, 54 

Breast-feeding, 48-75 (see also 
Milk, human), 
capacity for, 54-7 
contra-indications, 57-63 
difficulties, 56, 61-2, 68-72 
encouragement of, 71-2 
prevalence of, 55-6 
prolonged, 308-9 
rules for, 64-8 

Breast-pump, 53, 56-8. 237 

Broths, 175-6, 312-3 

Butter, 316 

Buttermilk, 115-8, 168, 233, 
235, 262 



Capfeix, 260 

Calcium, administration of 283, 
293-4, 301 
in cow's milk, 77 
in human milk, 50-1 
metabolism, 32, 35, 37-39, 

83, 285-7, 297 
soaps, 28, 33, 37, 83 

Calomel, 70, 259, 318 

Caloric feeding, 46-7 
requirement, 35, 43-7 
values, 44, 314-6 

Camphor, 260 

Carbohydrates, metabolism of, 
21, 30-5, 42, 83-4, 145-9, 
155-8, 222-5 (see also Dex- 
trin, Malt, Starch, Sugar). 

Carbon dioxid, 40 

Carcinoma and nursing, 60 

Cardiospasm, 215, 296 

Carrots, 179-80, 273, 314 



Cascara sagrada, 64, 318 

Casein in cow's milk, 78-9 
curds in feces, 28, 80-1 
in human milk, 50 

Casein-fat-milk, 141-2 

Castor oil, 69, 70, 195, 259, 282 

Cereals, 34, 147-8, 312-3, 316, 
319 (see also Barley, Oat- 
meal, Rice, Starch, Wheat- 
flour). 

Chlorids in cow's milk, 77 
in human milk, 50 

Cholera infantum, 101, 239 
(see also Dysentery). 

Cocoa, 314 

Cod-liver oil, 27, 294-5, 318 

Coffee, 65, 314 

Colic, 68-9, 193, 234 

Colostrum, 24, 48-9, 57 

Constipation, 21, 33, 69, 96, 
190-3, 317-8 
in nursing mothers, 64 
j Corpus luteum extract as gal- 

actagogue, 53 
I Cotton seed as galactagogue, 53 
I Cows, breeds of, 76-7, 125 

Crackers, 311-4, 319 
! Cream, 316 (see also Top-milk). 

Creatinin, 23, 25 

Curds, casein, 28, 80-1 
fat, 28, 80 

Custard, 316 

Cyanosis, 236 

Cystitis, 270 



Death-rate, 91-2, 245-8 

Decomposition, 235-8 (see also 
Atrophy). 

Dentition, 68, 217-8, 270, 289, 
318 

Dermatoses, metabolic, 278-82 

Dextrin, metabolism of, 31-3, 
145-6, 155-8 

Dextrose (see Glucose). 

Diarrhea, 22, 33, 69, 194-6, 238 
fat, 29, 196, 236 
from frozen milk, 101 
summer (see Dysentery). 



INDEX 



335 



Diastase, 17, 20, 31 

in human milk, 52 
Diet of nursing mother, 64-5 

of older infants, 311-6 
Digestion, 17-22 

disorders of, 22, 206-66 
Dispensaries, 106-7 
Drugs in milk, 65 
Duodenal digestion, 20 

tube, 20, 212 
Dysentery, 239, 243-66 

bacteriology, 248-51 

etiology, 91, 243-51 

pathology, 251-2 

prognosis, 254-5 

prophylaxis, 255-8 

serotherapy, 260-1 

symptoms, 252-4 

treatment, 258-66 
Dyspepsia, 233-5, 244 



E 



Eclampsia, nursing and, 59 
Eczema, infantile, 269, 278-80 

of nipples, 57 
Edema, 229-30, 236-7, 253, 304- 

5 
Eggs, 27, 176-8, 261, 281, 312-3, 

316-7 
Enemas, 192, 318 
Energy output, 43 

quotient, 44 

storage of, 44 
Enterokinase, 20 
Epilepsy, nursing and, 60 
Equilibrium, disturbed, 231-3, 

244 
Erepsin, 21 
Extractives, 164, 174-5 (see 

also Purin bodies). 
Exudative diathesis, 71, 267-72, 

279-80, 290 



Fats, chemical tests lor, 29 

in cow's milk, 76 

in human milk, 50-1 

metabolism of, 18, 25, 27-30, 
34, 38, 42, 82-3, 221-4, 
285-6 
Feces (see Stools). 
Feeding, artificial, 184-205 (see 
also Milk, cow's). 

caloric, 159-60 

duration, 66 

in fourth half-year, 313-6 

in second half-year, 198-9 

interval, 19, 65-6, 68-9, 126 

in third half-year, 311-3 

mixed, 199-201, 308-9 

night, 65-6, 69, 152 

percentage, 128-39, 

tables, 129, 139, 152 
, Fermentation, alcoholic, 169- 
70 

intestinal, 192, 234 

lactic acid, 32, 166-70 
Ferments, administration of, 
162-70 

in cow's milk, 74 

in human milk, 52 
Fever, contra-indication to 
nursing, 61 

inanition, 42 

in dysentery, 253 

salt, 225-8 

sugar, 110, 117, 144, 226, 
262-3 

thermic (see Heat-stroke). 

water in, 183 
Finkelstein's theory, 231-41 
Flies, 256 
Flour (see Starch). 
Foot and mouth disease, 90 
Formaldehyde, 65, 102 
Fruits (see also Apples, Oranges, 

Pineapples, Prunes), 316 



Farina, 312 

Fats, caloric value of, 35, 44-5 



Galactagogues, 53-4 

Galactose, 31 

Gases, metabolism of, 40 



336 



IXDEX 



Gastric juice, 17 (see also 

stomach) 
Glucose, 31 

Glycerophosphates, 38 
Glycogenic function, 31, 239 
Glycolytic ferments, 165-70 

(see also Diastase, Invertase, 

Lactase, Maltase). 
Goitre, exophthalmic, and 

nursing, 60 
Growth, 40, 198 
Gruels, 34, 147-9 
Gums, lancing of, 68 



Imperial Granum, 173 
Incubator, 44, 204-5 
Indigestion (see Dyspepsia). 
Indol, 32 

Infection, intestinal (see In- 
testinal Infection) . 
Infectious diseases, acute, and 

nursing, 61 
Infusion, saline, 228, 260 
Insanity and nursing, 60 
Intestinal fermentation, 192, 
234 

infection, 88-92, 222, 234, 
243-66 
Intestine, functions of, 18, 21-2, 
27, 31-2 

length, 21 
Intoxication, 100, 117, 144, 

226, 238-42, 262-3, 298 
Invertase, 21, 31 
Iron in cow's milk, 37, 77 

in human milk, 37, 50-1 

medication, 273 

metabolism, 37-8, 85-6, 272 



Heart disease and nursing, 60 
Heat, body and, 34, 44 

death rate and, 95, 244-7 

intestinal infection, and, 91, 
244-8 

stroke, and, 44, 247-8 

water metabolism, and, 40, 
182 
Hemoglobin, 38, 86, 272 

Hemp-soup, 180 J 

Hiccough (see Singultus). 
Hirschsprung's disease (see ! Junket, 118 

Megacolon). 
Hominy, 312 K 

Hospitalism, 53 
Hospitals, floating and seaside, I Kefir, 169-70 

256,258 Kumyss, 169-70 

Humidity, 44, 91 
Hydrogen peroxid, 74, 102 

"sulfid, 32 
Hydrolytic ferment in human 

milk, 52 
Hygiene, instruction in, 256-7 
Hj-pertony, 223, 295 (see also 

Muscular Rigidity). 
Hypophosphites, 38 
Hysteria and nursing, 60 



Icterus neonatorum, 20 
Ileocolitis (.see Dysentery). 



Lactalbumin (see Proteins, 

Whey). 
Lactase, 21, 31 
Lactoglobulin (see Proteins, 

Whey). 
Lactose (see Sugar, Milk). 
Lactosuria, 238 
Laryngospasm, 296, 299 
Lavage, 213, 259 
Laxatives, 64, 193, 317-8 
Lecithin, 38, 51-2, 96, 176 (see 

also Phosphorus). 



INDEX 



:;:;; 



Legumes, 178-9 
Lentils, 178 

Leukocytes and uric acid, 26 
Leukocytosis, 26, 238, 240 
Levulose (see Glucose). 
Lime (see Calcium). 
Lime-water, 161, 283 
Lipase, 17-8, 20, 27 

in human milk, 52 
Liver, 31, 289 
Lymphatism, 268, 271, 279 
Lymph-nodes, 289 



M 

Magnesium, administration of, 
193, 301, 318 
metabolism of, 28, 35, 38 
Malt, 233, 295, 318 (see also 
Dextrin, Maltose), 
as galactagogue, 54 
Maltase, 17, 21, 31 
Maltose, 31, 33, 145, 155-8 
Malt-soup, 155, 235 
Mastication, 318 
Mastitis (see Breast). 
Matzoon, 166-8 
Meat, 313, 316 
Meconium, 30, 42 
Megacolon, 214-5 
Mehlnahrschaden (see Atrophy 

from starch). 
Menstruation and nursing, 61 
Metabolism, disorders of, 267- 
307 
of carbohydrates, 21, 30-5, 

42, 145, 222-5 
of fats, 27-30, 42, 82-3, 221-4 
of gases, 40 
of proteins, 22-7, 42, 82, 220- 

1, 224-5 
of salts, 35-9, 83-6, 225-30, 

237, 272 
of water, 39-40, 181-3, 228-30 
Milchnahrschaden (see Atrophy 

from milk). 
Milk, acidified, 116, 166-70, 
262 
ass's, 110 



Milk, cow's, analysis of, 77-8 

bacteria in, 87-94 

bactericidal power of, 86-7 

blue, 76 

caloric value of, 76-7, 316 

certified, 93-4, 307 

composition of, 76-7 

condensed, 100-1, 303 

desiccated, 101, 303 

dilution of, 18, 111-2 

ferments in, 74, 96 

frozen, 101-2 

homogenized, 170-1, 303 

idiosyncrasy, 108-9 

malted, 155-8, 173, 304 

modified, 111-73 (see also 
Modification of milk). 

pasteurized, 94, 97-100, 
249, 304 

peptonized, 163-4 

preserved, 102-3 

raw, 81, 94 

regulations for, 93-6 

skimmed, 114 

sterilized, 91, 96-7, 300 

supply of, 92, 255 

whole, 107-8 
goat's, 110 

human, bactericidal power of, 
52 

caloric value of, 50 

composition of, 50-3 

drugs and, 65 

examination of, 63-4 

ferments in, 52, 74 

quality of, 61-2, 71 

quantity of, 54, 61-2, 69-70 
200 

preservation of, 74-5 

secretion of, 53-5 
laboratories, 130-2 
mare's, 110 

stations, 92, 103-7, 257-8 
Modification of milk, 111-173 

Backhaus', 164 

Baner's formula, 134-5 

Biedert's, 126-7 

Feer's, 122-3 

Finkelstein's, 118-22 (see 
also Albumin-milk) 



338 



INDEX 



Modification of milk, Gartner's, 
139-40, 303 

Heim and John's, 141-2 

home, 132-3, 137-8, 189-90 

Horlick's, 173 

Jacobi's, 149-54, 185-8 

Keller's, 155-8, 235, 304 

Liebig's, 155 

Meigs', 127-8 

Nestle's, 172, 233, 298 

Niemann's, 141 

Pfaundler's, 154-5 

Rotch's, 128-39 

Schloss', 143 

Szekely's, 140-1 
Mouth, care of, 58, 67 
Mucus in feces, 29, 252 
Muscular rigidity and spasm, 
147, 296, 298 (see also 
Hypertony). 



N 



Nephritis in dysentery, 240, 
253 

nursing and, 59-60 
Neuroses, digestive, 217-9 
Nervous diseases and nursing, 
60 

system and phosphorus, 39 
Newborn, metabolism of, 41-2, 

45 
Nipples (see Breast). 
Nitrogen (see also Proteins). 

intestinal, 23, 25 

metabolism of, 22-7, 42 
Nuclein, 26, 96 
Nursing (see Breast feeding) . 
Nystagmus, 296, 300 



Oatmeal, 34, 148, 191, 281, 

293, 312, 317 
Opium, 259 

Oranges, 181, 306-7, 314 
Osmosis, 36, 226 
Overfeeding, 68-9, 194 



Oxydase in human milk, 52 
Oxygen, 40 



Pacifiers, 67-8 

Pancreas, 20 

Pancreatic extract, addition to 

milk of, 163-4 
Parathyreoid glands, 297-8 
Pasteurization, 94, 97-100, 249 
Peaches, 181 
Peas, 178, 314 
Pepsin, 17 

addition to milk of, 163 
Peptones (see Albumose). 
Percentage feeding, 128-39 

tables, 129, 139 
Peristalsis (see Intestine, 

Stomach). 
Perspiration, 40, 182 
Pharyngospasm, 215, 296 
Phosphorus, administration of, 
293-5, 318 

in cow's milk, 77 

in human milk, 50-2 

metabolism, 38-9, 85, 285-7 
Phytin, 38 (see also Phos- 
phorus). 
Pineal gland extract as gal- 

actagogue, 53 
Pineapples, 181 
Pituitary gland extract as gal- 

actogogue, 53 
Pneumococcus, milk-borne, 94 
Potassium, administration of, 
155,277,298 

in cow's milk, 77 

in human milk, 50 

metabolism, 35-6, 84 

sulfocyanid, 17 

toxicity of, 36 
Potatoes, 179, 306, 314, 319 
Pregnancy, nursing, and, 61 
Premature infants, 201-205 
Premiums for nursing, 72 
Proteins, caloric value of, 44-5 

in colostrum, 24, 48-9 

in cow's milk, 76, 78-82 

in human milk, 50 



INDEX 



339 



Proteins, metabolism of, 18, 
21-7, 42, 82, 220-1, 224-5 
vegetable, 24-5, 156, 178, 224 
whey, 50, 78, 81 
Proteolytic ferments (see also 
Pepsin, Rennin, Trypsin), 
addition to milk of, 163-5 
in human milk, 52 
Purin bodies, 26, 175, 312 (see 

also Extractives). 
Putrefaction, intestinal, 32 
Pylorus, 18 

spasm of, 208-14, 296 
stenosis of, 206-14 



R 



Recreation piers, 256, 258-9 
Rennet (rennin), 17-8, 163 
Respiration, 40, 238 

Cheyne-Stokes, 236 
Rhubarb, 70, 193, 318 
Rice, 312 
Rickets, 96, 123, 157, 172-3, 

193, 271, 274, 284-302, 317 
Rontgen rays, 306 
Rumination, 216 



S 



Saliva, 17, 31 
Salt-fever, 225-8, 241-2 
Salts, in cow's milk, 35, 76-7, 
84-6 

in human milk, 35, 50-2 

metabolism of, 34-9, 225-30, 
237 
Salznahrschaden (see Atrophy 

from salts). 
Scarlet-fever, milk-borne, 90 
Scrofulosis, 267-8 
Scurvy, 96-7, 100-1, 123, 157, 

171-3, 181, 302-7 
Seaside hospitals, 256, 258 
Senna, 318 
Silica, 303 
Singultus, 216 
Skatol, 32 



Skim milk, 114 

Soaps, 28-9, 32, 37, 83, 196-8, 

232 
Sodium benzoate, 103 

bicarbonate, 161, 277, 283 

chlorid, 18, 35-6, 50, 77, 84, 
225-30 

citrate, 161-2, 283 

fluorid, 103 
Somatose (see Albumose). 
Soups (see Broths). 
Spasm, nodding, 296 
Spasmophilia, 295-302 
Spinach, 273, 314 
Spitting, 193-4 
Starch, metabolism, 31, 33-4, 

146-9, 222-4 (see also 

Atrophy from starch). 
Starvation, 18, 223-5, 236, 238, 
275, 277, 298 

treatment by, 69, 237, 261-2, 
280 
Sterilization, 91, 96-7, 300 
Stomach, 17-18, 21 
Stomatitis, 58 
Stools, blood in, 236, 253-4 

calcium in, 28, 37 

curds in, 28 

fats in, 27-9, 196, 236 

ferments in, 30 

green, 29-30, 69 

hunger, 70, 207 

in artificial feeding, 28-30, 
197 

mucus in, 29, 252 

normal, 27-30 

protein loss in, 23 

pus in, 253-4 

soap, 28-9, 37, 196-8, 232 
Streptococcus infection, milk- 
borne, 90-1, 94, 251 
Sucking, act of, 17 
Sugar and gastric secretion, 18 

intoxication, 100, 117, 144, 
222, 226, 262-3 

metabolism of, 30-5, 145, 222 
Sugar, cane, caloric value, 316 
metabolism, 31, 145 

milk-, in cow's milk, 76 
in human milk, 50-1 



340 



INDEX 



Sugar, milk-, metabolism, 31-2, 

83-4, 145 
Sulfur, metabolism, 39 
Suppositories, 192, 318 
Syphilis and nursing, 59, 73 



Tannin, 260 

Tea, 65, 314 

Teething (see Dentition). 

Teething-rings, 67 

Temperature of cities, 244-7 

indifferent, 44 
Tenements, 248, 256 
Tetany (see Spasmophilia). 
Thymus extract as galacta- 

gogue, 53 
Thyreoid extract and protein 

metabolism, 25 
Tomatoes, 314 
Tongue-tie, 68 
Top-milk, 123-41 
Trypsin, 20 

addition to milk, 163 
Tuberculosis, 267-8 

milk-borne, 90-1 

nursing and, 58, 73 
Twins, 50,^53 
Typhoid fever, milk-borne, 88-9 



U 



Underfeeding (see Starva- 
tion). 
Urea, 23 

Uremia and nursing, 59 
Uric acid, 26-7 



Urine, 23, 26-7, 38 
Urticaria, 279-82 



Vacuum bottle, 98-9 
Vegetables, 178-80, 314, 316-7 
Vernix caseosa, 42 
Vomiting, 21, 193-4 

neurotic, 218-9 

periodic, 276 



W 

Water, 181-3, 316 

matabolism, 36, 39-40, 228- 
30 
Weaning, 308-11 
Weight, 26, 40-2, 316 
Wet-nursing, 72-4 
Wheat-flour, 34, 148 
Whey, 112-5, 262 

proteins, 50, 78, 81 
Whey-modified milk, 143 
Whooping cough, 300 
Worms, intestinal, 281-2 



Yeast, 169-70 
Yoghourt (see Matzoon). 



Z 

Zoolak (see Matzoon). 



IWV&XX 









■.■.■■••■■■-■■:■ 



■ 



)®m 



SHI 



■■■,■■■.',■■;""■■■,' 

■■;■■■--■■ -'V"' 




Shi 

B§?3 

ErafS 













Wfm 




■ ll frffi 



